PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy 40 and 5/7 weeks' gestation.
2. Placental abruption.
3. Uterine atony.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy 40 and 5/7 weeks' gestation.
2. Placental abruption.
3. Uterine atony.
4. Delivered.
OPERATIONS PERFORMED:
1. Primary low transverse cesarean section.
2. Supracervical abdominal hysterectomy.
SURGEON: John Doe , MD
FIRST ASSISTANT: Jane Doe , MD
SECOND ASSISTANT: Bradford Doe, MD
ANESTHESIA: Epidural and general.
ESTIMATED BLOOD LOSS: 2250 mL.
IV FLUIDS: 3700 mL crystalloid.
URINE OUTPUT: 650 mL, blood tinged.
COUNTS: Correct.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old primigravida at 40 and 5/7 weeks’ gestation who presented with spontaneous onset of labor. Amniotomy revealed clear fluid. Labor was augmented with oxytocin. The patient made very slow progress from 5 cm to 7 cm of dilation. Additionally, the patient was noted to have a steady trickle of vaginal bleeding and an acute onset of intense left upper quadrant pain despite epidural analgesia. This was felt consistent with a diagnosis of placental abruption and a decision was therefore made to proceed with cesarean delivery. Indications, risks, and benefits were discussed with the patient and her spouse. These risks include, but are not limited to bleeding, infection, damage to abdominal or pelvic organs or possible hemorrhage requiring transfusion. Consent was obtained.
OPERATIVE FINDINGS: Viable male infant weighing 6 pounds 6 ounces of 2880 grams with Apgar score of 9 at one minute and 9 at five minutes. Uterus was atonic with especially thin uterine wall noted in the area of the left cornua. Tubes and ovaries appeared normal.
DESCRIPTION OF OPERATION: After induction of epidural anesthesia, the patient was placed in the supine position with left lateral uterine displacement. The patient was prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made with a scalpel and extended sharply to the fascia, which was nicked at its mid point. The fascial incision was extended bilaterally. The fascia was bluntly and sharply dissected from the underlying rectus muscles. The recti were bluntly divided. The peritoneum was tented upward and entered sharply. Then incision was extended superiorly and inferiorly. The vesicouterine peritoneum was tented upward and entered sharply. Then, the incision was extended bilaterally. A bladder flap was created by blunt dissection and protected behind the bladder blade. A low transverse uterine incision was made with a scalpel and extended bilaterally with scissors. The operator's hand was inserted and the fetal vertex elevated to the level of the incision, where it was delivered with the aid of fundal pressure. The nose and mouth was bulb suctioned. The remainder of the infant was delivered atraumatically. The cord was doubly clamped and cut. The infant was handed to the awaiting nursery staff. The uterus was exteriorized and wrapped with a moist sponge. A dry sponge was used to curette the endometrial cavity. The uterus was vigorously massaged, as it was noted to be atonic with the left cornual aspect of the uterus notably more boggy than the rest. The uterine wall was also noted to be somewhat thinned in this aspect of the uterus.
The patient was given 10 units of oxytocin into the uterine muscle as well as 20 units in her IV fluids. The uterine incision was closed in two layers using 0 chromic suture in a running locked fashion with second layer in an imbricating fashion. Additional figure-of-eight suture was used as needed for hemostasis. The uterus remained boggy and the patient was given methadone 0.2 mg into the uterine muscle. Uterine massage was continued with no response. In fact, the uterus was noted to be boggier and more atonic and was enlarging in size. The patient was subsequently given Hemabate 250 mcg intramuscularly. Continued uterus massage revealed no response. She then received an attempt at intrauterine injection of Methergine, but this was unsuccessful due to return of blood in each place where the needle was inserted. The patient received an additional two doses of 250 mcg each of Hemabate, which were given intrauterinely plus 800 mcg of Cytotec intravaginally and a fourth dose of Hemabate 250 mcg intramuscularly, all with no response. The uterus became more and more boggy and persistently enlarged. The uterine massage and direct uterine pressure were continued throughout.
Decision was made to proceed with a B-Lynch suture. This was performed initially using number 1 Vicryl. As the suture was cinched down, it tore through the lower uterine segment. It was tied in situ and a figure-of-eight suture was used for hemostasis at the site where the suture had torn through. The B-Lynch suture was then repeated using 0 chromic. As this was cinched down, however, the suture broke while the knot was being tied. It was difficult to cinch down either suture due to the significant enlargement of the uterine fundus. At this time, decision was made to proceed with cesarean hysterectomy for persistent uterine atony unresponsive to conservative management. Consent was obtained.
The left round ligament was grasped, doubly clamped, cut, and doubly ligated. Note that throughout the hysterectomy, 0 Vicryl sutures were used and all pedicles were doubly ligated. The right round ligament was similarly clamped, cut, and ligated. The left utero-ovarian ligament was then doubly clamped, cut, and doubly ligated. Additional clamps were placed down the mesosalpinx to the level of the uterine vessels. A similar procedure was performed on the right utero-ovarian ligament and along the right mesosalpinx and broad ligament, to the level of the uterine vessels. The left uterine artery was then clamped, cut, and doubly ligated. A similar procedure was performed on the right uterine artery. Decision was made at this point to perform a supracervical hysterectomy. Large Kelly clamps are placed across the right and left sides of the cervix, meeting at the midpoint. A scalpel was used to excise the uterus, which was passed off the operative field.
Interrupted figure-of-eight sutures of 0 Vicryl were used to close the cervix. Once the cervical closure was hemostatic, the remaining pedicles were re-examined. Additional interrupted sutures were used as needed for hemostasis of the fallopian tubes and round ligament pedicles. The pelvis was irrigated. Hemostasis of all pedicles and the cervical closure was reconfirmed. Interceed was placed over the cervical stump to serve as an adhesion barrier. The peritoneum was closed with a running suture of 2-0 chromic. The subfascial surfaces were examined and noted to be hemostatic. The fascia was closed using 0 Vicryl in a running fashion, interrupted at the midpoint. The skin was irrigated. Hemostasis was achieved with electrocautery. The skin was closed with staples. A sterile dressing was applied. The patient did receive 2 grams of Ancef preoperatively and this will be continued for 24 hours postoperatively.
DISPOSITION: The patient returned to the postanesthesia care unit awake and in stable condition.
