OPERATION IN DETAIL: The patient was taken to the operating room where she was placed under general anesthesia and prepped and draped in the dorsal lithotomy position. Cystoscopy and bilateral ureteral stents were placed. The patient was then placed in the supine position and again reprepped and draped. A transverse incision was made through the skin with a scalpel and carried through to the underlying layer of fascia with a Bovie. The Bovie was nicked in the midline and this incision was extended laterally using the Bovie. The inferior epigastric vessels were visualized at the lateral edges of the rectus abdominis muscle bilaterally and these were doubly clamped, cut, and suture ligated with 3-0 Vicryl free ties. The rectus muscles were then separated in the midline and transected using the Bovie. The peritoneum was then identified and tented up with pickups and entered sharply with Metzenbaum scissors. This incision was extended laterally using the Bovie. Pelvic washings were then obtained at this time. The uterus was palpated and noted to be about 21-week size and with large fundal fibroid and large fibroid in the right lower uterine segment. An O'Connor-O'Sullivan self-retaining retractor was placed in the abdomen and the upper abdomen explored, noting normal liver and kidneys bilaterally. The bowel was then packed away with moist laparotomy sponges and the round ligament identified on the right side, doubly clamped with Mayo clamps, cut, and then suture ligated with 1 chromic. The utero-ovarian ligament was then isolated and the ureter with stent palpated on the right side as well. The utero-ovarian ligament on the right side was doubly clamped, cut, and suture ligated with 1 chromic. The bladder flap was then created on the right, followed by identical procedure on the left side, where the round ligament was isolated, doubly clamped, cut, and suture ligated with 1 chromic. The utero-ovarian ligament in the left was identified, doubly clamped, cut, and suture ligated. The ureter with stent on the left was also palpated and identified. The bladder flap was created on the left to meet the vesicouterine peritoneal flap on the right. The bladder was pushed down with a sponge stick. The large fibroid in the right lower uterine segment was then removed at this time, first by using the Bovie to free the overlying tissues. The fibroid was then grasped with a Lahey clamp and truncated in space using a Bovie. The uterine arteries were then skeletonized bilaterally and doubly clamped, cut, and suture ligated with 1 chromic. The cardinal ligaments bilaterally were then clamped, cut, and suture ligated with 1 chromic as well. It was noted at this point that the patient did have some endometriosis in the cul-de-sac causing the colon to be adhesed in the posterior cul-de-sac near the lower edge of the cervix. At this point, a subtotal hysterectomy was decided to be performed. The uterus was then truncated above the level of the cervix and sent off to pathology. The inferior aspect of the lower uterine segment and cervix was then reapproximated with figure-of-eight stitches of 0-Vicryl. Excellent hemostasis was obtained. The abdomen was then irrigated and small oozing coagulated with Bovie. Again, bilateral ureters were identified and followed up from the bifurcation of the internal iliacs to the bladder. CoSeal was then sprayed over the site of the cervical closure, over the adnexa bilaterally and the posterior cul-de-sac. Once laparotomy sponges and self-retaining retractors were removed and the peritoneum reapproximated with 3-0 Vicryl, the fascia was then reapproximated with 0-PDS in running fashion. The subcutaneous layer was irrigated and reapproximated with 3-0 Vicryl. The skin was closed with 4-0 Monocryl in a subcuticular stitch and Benzoin and Steri-Strips were placed over the incision site. The bilateral ureteral stents were then removed at this time. The patient tolerated the procedure well. Sponge, lap, needle, instrument counts were correct x2.
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