PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy, 36 and 6/7 weeks.
2. History of low transverse cesarean section x2.
3. Early labor.
4. History of breast cancer status post bilateral mastectomy.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy, 36 and 6/7 weeks.
2. History of low transverse cesarean section x2.
3. Early labor.
4. History of breast cancer status post bilateral mastectomy.
5. Abdominal and pelvic adhesions.
OPERATION PERFORMED: Repeat low transverse cesarean section via Pfannenstiel incision and lysis of adhesions.
SURGEON: John Doe , MD
ASSISTANT: Jane Doe , MD
ANESTHESIA: Spinal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 800 mL.
IV FLUIDS: 2200 mL.
URINE OUTPUT: 250 mL of yellow urine.
OPERATIVE FINDINGS: Dense abdominal wall adhesions were noted with the rectus muscles densely adhesed to the overlying fascia. The rectus muscles were adhesed in the midline. The bilateral tubes and ovaries were normal and the uterus was normal other than dense adhesions of the bladder to the lower uterine segment. A viable male infant was delivered with clear amniotic fluid. The weight was 7 pounds 8 ounces and Apgars were 8 and 9.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old G3, P2-0-0-2 at 36 and 6/7 weeks who presented to the office with complaints of regular painful contractions about every 5 to 7 minutes. The patient's history is significant for previous lower transverse cesarean sections at 37 weeks for spontaneous labor. At the office visit, the patient was noted to be 1 cm dilated with blood-tinged discharge and the diagnosis of early labor was made. Risks, benefits and alternatives of repeat cesarean section at this gestation versus continued expectant management were discussed with the patient. The risks of delivery and complications of prematurity were discussed. Consent was obtained. The patient was sent to the hospital. Fetal heart rate monitoring in the labor and delivery recovery room area was reassuring.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where spinal anesthesia was placed and found to be adequate. The patient was placed in the dorsal supine position with a leftward tilt. A Foley catheter was placed and the abdomen was prepped in the usual sterile fashion and draped. A Pfannenstiel incision was then made approximately 2 cm above the pubic symphysis and overlying the previous Pfannenstiel incisions. The incision was carried down to the underlying fascia with a scalpel. The fascia was incised in the midline and extended laterally with a scalpel. The superior aspect of the incision was grasped with Kocher clamps and the underlying rectus muscles were carefully dissected off using sharp dissection. The same procedure was performed inferiorly. Due to the extensive adhesions in this area, small venous oozing areas were made hemostatic with Bovie cautery at this time. The rectus muscles were then separated high in the incision with the scalpel and the peritoneum was identified and elevated with hemostat. The peritoneum was entered with a scalpel. A finger was advanced through the peritoneal incision and the anterior abdominal wall was noted to be free of adhesions allowing the peritoneal incision to be extended superiorly and inferiorly. At the inferior aspect of the incision, the bladder was noted to be high onto the peritoneum. The bladder blade was inserted and the scarred bladder was visualized and the vesicouterine peritoneum was identified and entered sharply. An attempt to create the bladder reflection was made with oozing noted from the adhesions present on the bladder.
Once the bladder was felt to be safely dissected off the lower uterine segment, the uterus was incised in the transverse fashion with a scalpel. The incision was extended with Mayo scissors. The infant's head was delivered atraumatically and the nose and mouth were bulb suctioned. The infant was delivered and placed onto the surgical field where the cord was clamped and cut. The infant was handed off to the awaiting nursery personnel. Cord bloods were obtained. The placenta was manually removed intact. The uterine fundus was noted to be free of adhesions and was delivered through the abdominal incision. The bladder blade was reinserted and the uterus was cleared of all clots and debris. The extent of the uterine incision was grasped with Pennington clamps and 0 chromic suture was used to reapproximate the incision in a running locked fashion. A second layer of the same suture was then used to imbricate the first layer. With the placement of the second layer of sutures, hematoma developed in the right aspect of the uterine incision extending down into the broad ligament. An O'Leary suture was placed superior to the uterine incision with continued expansion of the hematoma. A second O'Leary stitch was then placed inferior to the incision with excellent control of the bleeding in this area. Diffuse oozing was noted from the lower aspect of the uterine incision related to the previous bladder adhesions and these were made hemostatic either with Bovie cautery or multiple figure-of-eight sutures of 0 chromic.
Attention was then turned to the bladder and extensive diffuse oozing was noted from the anterior of this reflection. Attempts at Bovie cautery were unsuccessful and interrupted 3-0 Vicryl sutures were placed in the area to finally obtain hemostasis. Given the extent of adhesions, the decision was made to retrograde fill the bladder with sterile milk to confirm the integrity of the bladder, and this was done successfully with no leaks of milk noted into the surgical field. Once hemostasis was assured, the uterus was returned to the patient's abdomen and the pelvis and abdomen were irrigated and the gutters were cleared of all clots and debris. Seprafilm was placed over the uterine incision and the bladder reflection brought up and placed over the Seprafilm.
The peritoneal edges were reapproximated using 2-0 Vicryl running stitch, and with the placement of the suture, continued red oozing was noted from the abdominal cavity, and the peritoneal incision was opened again and the uterus was reinspected and hemostasis confirmed. The bladder was again reinspected and hemostasis was confirmed. The peritoneal incision was again closed using a 2-0 Vicryl running stitch. The rectus muscles were inspected again and the right rectus muscle was noted to have significant amount of bleeding from one perforator, which required placement of figure-of-eight 3-0 Vicryl suture x2. Once hemostasis was assured, the fascia was reapproximated using 0 PDS suture in a running fashion to the midline. The subcutaneous layer was irrigated and made hemostatic with Bovie cautery. Interrupted 3-0 Vicryl sutures were placed in the subcutaneous. Given the extent of the surgical time, the spinal anesthesia was beginning to wear off and the patient was experiencing mild pressure and discomfort with the surgery at this point and 15 mL of 0.5% Marcaine with epinephrine were then injected into the incision and the skin was closed with staples. All sponge, lap, and needle counts were correct x3. The patient remained in good condition throughout the procedure and was taken to the recovery room. The male infant was taken to the nursery prior to conclusion of the cesarean section in good condition.
