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Laparoscopic Bilateral Tubal Ligation Medical Transcription Sample Report

PREOPERATIVE DIAGNOSIS:  Multiparity, desires permanent sterilization.

POSTOPERATIVE DIAGNOSIS:  Multiparity, desires permanent sterilization.

PROCEDURE PERFORMED:  Laparoscopic bilateral tubal ligation with Filshie clips.

SURGEON:  John Doe, MD





FINDINGS:  Normal uterus, tubes, and ovaries.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room where general anesthesia was obtained without difficulty. The patient was then examined under anesthesia and found to have a small anteverted uterus and normal adnexa. She was placed in the dorsal lithotomy position and prepared and draped in the normal sterile fashion. A sterile speculum was then placed in the patient's vagina and the anterior lip of the cervix grasped with a single-toothed tenaculum and a uterine manipulator advanced into the uterus to provide a means of uterine manipulation during the surgery. The speculum was removed from the vagina at this time.

Attention was then turned to the patient's abdomen where a small skin incision was made in the umbilical fold. At this time, a 5 mm Optiview scope was carefully introduced into the peritoneal cavity under direct visualization while tenting the abdominal wall. Intraperitoneal placement was confirmed visually. At this time, the camera and blade were removed and the camera was reintroduced into the trocar with visualization of the abdominal cavity. At this time, CO2 was connected to the trocar and insufflation was begun. The pneumoperitoneum was obtained with approximately 3 to 4 L of CO2 gas. After insufflation, a full survey of the abdominal cavity was done, and there were no abnormalities visualized. At this time, a second skin incision was made 2 cm above the symphysis pubis, in the midline, and a second 7 to 8 mm trocar and sleeve were advanced under direct visualization.

At this time, a Filshie clip applicator was advanced through the second trocar sleeve and the patient's left fallopian tube was identified and followed to the fimbriated end. The Filshie clip applicator was then used to apply the clip in the mid isthmic area of the tube. The clip was noted to be applied to include the entire circumference of the fallopian tube. There was no bleeding noted at this time. The Filshie clip applicator was then removed and reloaded, and the patient's right tube identified in a similar fashion and easy application of the Filshie clip in the same fashion was completed.

The instruments were then all removed from the patient's abdomen and pneumoperitoneum resolved. The incisions were then closed with Dermabond. The uterine manipulator was then removed from the cervix and vagina. There was no bleeding noted from the cervix. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x 2. The patient was taken to the recovery room in stable condition.

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