DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Symptomatic pelvic organ prolapse.
2. Pelvic pressure.
3. Third-degree cystocele.
POSTOPERATIVE DIAGNOSES:
1. Symptomatic pelvic organ prolapse.
2. Pelvic pressure.
3. Third-degree cystocele.
PROCEDURES PERFORMED:
1. Laparoscopically-assisted total vaginal hysterectomy.
2. Bilateral salpingo-oophorectomy.
3. Anterior colporrhaphy.
SURGEON: John Doe, MD
ANESTHESIA: General with endotracheal tube intubation.
ESTIMATED BLOOD LOSS: Less than 100 mL.
COMPLICATIONS: None.
DRAINS: Foley with clear urine return.
SPECIMENS:
1. Uterine cervix and fundus.
2. Bilateral adnexa.
3. Redundant vaginal mucosa.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and prepped and draped in the dorsal lithotomy position for vaginal and abdominal procedures. A red rubber catheter was used to drain the patient's bladder. Two vaginal retractors were placed in the vagina to visualize the cervix, which was grasped on the anterior cervical lip with a single-tooth tenaculum. A Hulka uterine manipulator was inserted into the endocervix, attached to the anterior cervical lip. The single-tooth tenaculum was removed as well as the vaginal retractors. Focus was then turned toward the abdominal portion of the procedure. A subumbilical skin incision was made with the knife. The abdomen was tented up and an 11 mm bladeless trocar was inserted under direct visualization with the laparoscope. CO2 gas was used to create a pneumoperitoneum and the bowel and omentum underlying the insertion site were inspected and found to be free of injury. Two additional trocars were placed, one in each midclavicular line, half the distance from the pubis to the umbilicus, by scoring the skin with a knife and inserting 12 mm bladeless trocars under direct visualization with the laparoscope. A laparoscopic Babcock was used to grab the ovary and to place traction on the infundibulopelvic ligament. Endo-GIA was inserted and the infundibulopelvic ligament was stapled and transected. An additional fire was performed to get the round ligament and some of the broad ligament. The same procedure was performed on the contralateral side. There was no evidence of active bleeding. At this point, focus was returned back to the vaginal portion of the procedure. The Hulka manipulator was removed from the patient's cervix. Vaginal retractors were re-placed. The cervix was grasped anterior to posterior with two single-tooth tenacula. A posterior colpotomy was made with Mayo scissors and the peritoneal cavity was entered. A stitch of 0-Vicryl suture was placed at 6 o'clock to attach the peritoneum to the vaginal cuff. A Heaney retractor was placed in the peritoneal cavity to hold the bowel posteriorly. A knife was used to cut the cervix off the vagina. The endopelvic fascia was then bluntly dissected. The uterosacral ligaments were clamped with Heaney clamps, transected with Mayo scissors and suture ligated with 0-Vicryl suture in Heaney stitch fashion. Bites were taken through the cardinal ligaments with Heaney clamps, transecting the pedicle with Mayo scissors and suture ligating with 0-Vicryl suture. The anterior cul-de-sac was entered sharply. An additional Heaney retractor was placed to hold the bladder anteriorly. The remainder of the bites was taken in such as fashion as to reapproximate the anterior and posterior leaflets of the broad ligament. The uterine vasculature was clamped with Heaney clamps, transected with Mayo scissors and suture ligated with 0-Vicryl suture. An additional bite was taken above through the utero-ovarian pedicle, transecting the pedicle with a knife and suture ligating with 0-Vicryl suture. There was a small attachment for each ovary to its broad ligament, which was clamped with Kelly clamps, transected and suture ligated with 0-Vicryl suture. The pedicles were inspected and found to be hemostatic. The peritoneum was closed in a pursestring fashion using 2-0 Vicryl suture. The vaginal mucosa overlying the cystocele was undermined and incised sharply in the midline and extended until approximately 2 cm from the urethral meatus. Sharp and blunt dissection of the endopelvic fascia dissecting the vagina off the bladder was then performed. Stitches of 2-0 Vicryl suture were placed in a Kelly plication fashion to reapproximate the endopelvic fascia to provide support to the bladder neck. Redundant vaginal mucosa was trimmed. The anterior vaginal wall incision was closed using 2-0 Vicryl suture in a running locked fashion to the level of the vaginal cuff. A Foley catheter was placed and clear urine was appreciated. The remainder of the cuff was closed using 0-Vicryl suture in interrupted figure-of-eight fashion. The vagina was packed with 1 inch Iodoform tape. Again, the focus was turned to the abdominal portion of the procedure. The CO2 gas was allowed to reaccumulate and the pelvic contents were inspected. There was no evidence of bleeding from any pedicle. The trocars were removed after letting the CO2 gas escape. The skin incisions were closed using 4-0 Monocryl in subcuticular fashion. At the end of the procedure, sponge, needle and instrument counts were all correct. The patient tolerated the procedure well and was taken to the recovery room, will be transferred to the floor when stable.
PREOPERATIVE DIAGNOSES:
1. Symptomatic pelvic organ prolapse.
2. Pelvic pressure.
3. Third-degree cystocele.
POSTOPERATIVE DIAGNOSES:
1. Symptomatic pelvic organ prolapse.
2. Pelvic pressure.
3. Third-degree cystocele.
PROCEDURES PERFORMED:
1. Laparoscopically-assisted total vaginal hysterectomy.
2. Bilateral salpingo-oophorectomy.
3. Anterior colporrhaphy.
SURGEON: John Doe, MD
ANESTHESIA: General with endotracheal tube intubation.
ESTIMATED BLOOD LOSS: Less than 100 mL.
COMPLICATIONS: None.
DRAINS: Foley with clear urine return.
SPECIMENS:
1. Uterine cervix and fundus.
2. Bilateral adnexa.
3. Redundant vaginal mucosa.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and prepped and draped in the dorsal lithotomy position for vaginal and abdominal procedures. A red rubber catheter was used to drain the patient's bladder. Two vaginal retractors were placed in the vagina to visualize the cervix, which was grasped on the anterior cervical lip with a single-tooth tenaculum. A Hulka uterine manipulator was inserted into the endocervix, attached to the anterior cervical lip. The single-tooth tenaculum was removed as well as the vaginal retractors. Focus was then turned toward the abdominal portion of the procedure. A subumbilical skin incision was made with the knife. The abdomen was tented up and an 11 mm bladeless trocar was inserted under direct visualization with the laparoscope. CO2 gas was used to create a pneumoperitoneum and the bowel and omentum underlying the insertion site were inspected and found to be free of injury. Two additional trocars were placed, one in each midclavicular line, half the distance from the pubis to the umbilicus, by scoring the skin with a knife and inserting 12 mm bladeless trocars under direct visualization with the laparoscope. A laparoscopic Babcock was used to grab the ovary and to place traction on the infundibulopelvic ligament. Endo-GIA was inserted and the infundibulopelvic ligament was stapled and transected. An additional fire was performed to get the round ligament and some of the broad ligament. The same procedure was performed on the contralateral side. There was no evidence of active bleeding. At this point, focus was returned back to the vaginal portion of the procedure. The Hulka manipulator was removed from the patient's cervix. Vaginal retractors were re-placed. The cervix was grasped anterior to posterior with two single-tooth tenacula. A posterior colpotomy was made with Mayo scissors and the peritoneal cavity was entered. A stitch of 0-Vicryl suture was placed at 6 o'clock to attach the peritoneum to the vaginal cuff. A Heaney retractor was placed in the peritoneal cavity to hold the bowel posteriorly. A knife was used to cut the cervix off the vagina. The endopelvic fascia was then bluntly dissected. The uterosacral ligaments were clamped with Heaney clamps, transected with Mayo scissors and suture ligated with 0-Vicryl suture in Heaney stitch fashion. Bites were taken through the cardinal ligaments with Heaney clamps, transecting the pedicle with Mayo scissors and suture ligating with 0-Vicryl suture. The anterior cul-de-sac was entered sharply. An additional Heaney retractor was placed to hold the bladder anteriorly. The remainder of the bites was taken in such as fashion as to reapproximate the anterior and posterior leaflets of the broad ligament. The uterine vasculature was clamped with Heaney clamps, transected with Mayo scissors and suture ligated with 0-Vicryl suture. An additional bite was taken above through the utero-ovarian pedicle, transecting the pedicle with a knife and suture ligating with 0-Vicryl suture. There was a small attachment for each ovary to its broad ligament, which was clamped with Kelly clamps, transected and suture ligated with 0-Vicryl suture. The pedicles were inspected and found to be hemostatic. The peritoneum was closed in a pursestring fashion using 2-0 Vicryl suture. The vaginal mucosa overlying the cystocele was undermined and incised sharply in the midline and extended until approximately 2 cm from the urethral meatus. Sharp and blunt dissection of the endopelvic fascia dissecting the vagina off the bladder was then performed. Stitches of 2-0 Vicryl suture were placed in a Kelly plication fashion to reapproximate the endopelvic fascia to provide support to the bladder neck. Redundant vaginal mucosa was trimmed. The anterior vaginal wall incision was closed using 2-0 Vicryl suture in a running locked fashion to the level of the vaginal cuff. A Foley catheter was placed and clear urine was appreciated. The remainder of the cuff was closed using 0-Vicryl suture in interrupted figure-of-eight fashion. The vagina was packed with 1 inch Iodoform tape. Again, the focus was turned to the abdominal portion of the procedure. The CO2 gas was allowed to reaccumulate and the pelvic contents were inspected. There was no evidence of bleeding from any pedicle. The trocars were removed after letting the CO2 gas escape. The skin incisions were closed using 4-0 Monocryl in subcuticular fashion. At the end of the procedure, sponge, needle and instrument counts were all correct. The patient tolerated the procedure well and was taken to the recovery room, will be transferred to the floor when stable.
