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After successful induction of general anesthesia, the patient was placed in the lithotomy position. Abdomen, perineum and vagina were prepped and draped in a routine fashion. The urinary bladder was catheterized with a Foley catheter and emptied.

Pelvic examination was performed. Vulva and vagina were multiparous, cervix regular. Uterus normal size. Adnexa not palpable.

The weighted Sims speculum was inserted. The cervix was grasped with the single- toothed tenaculum. The uterine cavity was sounded to 10-cm and was regular. The cervix was dilated to Hegar #4 and a HUMI cannula was inserted and the abdomen prepared for laparoscopy.

A small cut was made in the center of the umbilicus, passed the Veress needle and introduced three liters of carbon dioxide. The incision was extended and the trocar was passed. Through the trocar, the laparoscope was passed with both tubes identified; they were normal. Both ovaries were normal. Cul-de-sac was normal.

An anterior puncture was performed and a 5-mm trocar was introduced. Through the trocar, the bipolar forceps were passed. The right tube was grasped in the center and this segment cauterized. Grasping proximally next to it, another segment was cauterized. There was whitish-yellowish tissue typical for completely burned tube. The same procedure was completed on the other side. The scissors were then passed and the tubes were cut on each side, and the ends again coagulated. There was no bleeding.

The anesthesiologist was instructed to give 2 gm of Cefotan. The pneumoperitoneum and the instruments were removed under direct vision. The skin was closed with 3-0 Dexon and the HUMI removed.

C-section for abruption.

PREOPERATIVE DIAGNOSES:  Sudden onset of heavy bleeding per vagina while pushing; abruptio placenta.

POSTOPERATIVE DIAGNOSES:  Sudden onset of heavy bleeding per vagina while pushing; abruptio placenta.

TITLE OF SURGERY:  Primary cesarean section, low-transverse uterine incision.


DESCRIPTION OF PROCEDURE: With the patient under satisfactory epidural anesthesia in the dorsal supine position, a quick preparation and draping for sterile abdominal surgery was carried out. A Pfannenstiel incision was made approximately 3 cm above the pubic bone. The subcutaneous layers and anterior rectus fascia were cut along the skin incision. Bleeding points were ignored except for some larger ones which were cauterized with a Bovie. The fascia was dissected sharply and bluntly away from the underlying rectus and pyramidalis muscles. The muscles were split in the midline and displaced bilaterally. The parietoperitoneum was incised in the midline from the edge of the bladder to the level of the umbilicus.

A bladder blade was placed in the incision. The visceroperitoneum on the lower uterine aspect was elevated, nicked, undermined bilaterally, and cut transversely. The peritoneal bladder flap was developed. A smiling-type incision was made with a scalpel blade on the lower uterine aspect and the endometrial cavity was entered in the midline. The incision was extended bilaterally with an index finger.

The infant's head was brought out from the pelvis and delivered with fundal pressure uneventfully through the incision. The nose and mouth were suctioned. The remainder of the infant's body was delivered. The nuchal cord was clamped twice and cut, and the infant was handed over to the pediatrician in attendance. It was a live female infant weighing 7 pounds 14 ounces. She received Apgar scores of 8 and 9.

After securing cord blood in the usual manner, the placenta was delivered spontaneously. Examination of the placenta on the maternal side revealed a midportion which was covered with dark clots; approximately 1/4 of the margin had a similar appearance. The placenta looked heavily aged and calcified. The edges of the uterine incision were grasped with ring forceps. The uterus was delivered through the incision. The uterine incision was closed in two layers with #1 chromic. The first layer was done in a running-locking fashion and the second one in a horizontal Lembert-type fashion inverting the fascial edges. Hemostasis was satisfactory.

Examination of the adnexa revealed an approximately 5- to 6-cm cyst of Morgagni on the left adnexa in fairly close proximity to the oviduct in the ampullary infundibular area. The cyst was very carefully dissected and sent to the pathology lab for examination.

The raw area was reperitonealized with a 4-0 chromic suture. Hemostasis was satisfactory. The uterus was repositioned within the abdominal cavity. The visceroperitoneum was closed with 2-0 chromic suture. The pelvic and abdominal cavity were rinsed with copious amounts of saline solution. The abdominal wall was closed in layers as follows:

The parietoperitoneum was closed with 2-0 chromic. The muscles were approximated in the midline with 2-0 chromic. The anterior rectus fascia was closed in 0-Vicryl in running-locking fashion. The subcutaneous layers were closed with 3-0 plain gut. The skin was closed with 4-0 Prolene in a subcuticular manner reinforced with Steri-Strips. A dressing was placed over the incision.

Estimated blood loss in the delivery room was 700 cc. In labor and delivery, in a very short period of time before taking the patient to cesarean section, estimated blood loss was 350 cc. Replacement:  See anesthesia notes. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.

Cystourethroscopy, left retrograde ureteropyelogram and left dismembered pyeloplasty.

Left ureteropelvic junction obstruction.

Left ureteropelvic junction obstruction.

General endotracheal anesthesia.

DESCRIPTION: The patient was brought to the operating room and underwent general anesthesia. He was placed in the dorsal lithotomy position. He was prepared and draped in the usual manner. The 9.5 pediatric cystoscope was placed in the bladder and a #3 ureteral catheter was placed through the torquing channel. A left retrograde ureteropyelogram was obtained. This showed a clear obstruction at the junction of the left ureteropelvic junction. The cystoscope and stent were then removed.

The patient was then placed in the left-flank-up position. An incision was made off the tip of the 12th rib with a #15 blade. Bleeding was controlled utilizing electrocautery. The muscle fibers were all incised in the flank with electrocautery. Two Richardson retractors were placed. Gerota's fascia was opened in a vertical fashion and the kidney was delivered. The ureter was found in the retroperitoneal space and dissected out to the level of the renal pelvis. There was clear obstruction and kinking at the level of the ureteropelvic junction. Markings sutures were placed in the ureter and the renal pelvis with 6-0 Vicryl. The obstructive segment was excised and the tenth renal pelvis was then decompressed. An oblique anastomosis was then effected between the upper ureter which had been spatulated and the renal pelvis. This was accomplished with two sutures of 6-0 Vicryl at the apices and then running sutures on the anterior and posterior wall with 6-0 Vicryl. Prior to completing the anterior anastomosis, a 10-French Malecot catheter was used as a nephrostomy tube and brought with the nephrostomy needle through the substance of the kidney and was brought out through the flank, and it was sewn to the flank with 4-0 Prolene. The anterior aspect of the anastomosis was then completed after a #3 pediatric feeding tube was placed through the anastomosis andŌ to be watertight. The kidney was returned to the renal space. Gerota's fascia was left open in the caudad portion. A Penrose drain was placed through a stab wound and brought down to the inferior portion below the anastomosis. This was sewn to the skin with 4-0 nylon. The muscle layers were then closed with running 3-0 Vicryl. The subcutaneous layer was closed with 4-0 Vicryl and the skin was closed with a running subcuticular 3-0 Prolene suture. There were no intraoperative complication. The patient was discharged to the recovery room in satisfactory condition.

Operative hysteroscopy with lysis of adhesions, tubal cannulation, intrauterine device insertion and diagnostic laparoscopy.

Severe Asherman syndrome.

Severe Asherman syndrome.

General endotracheal anesthesia.

Paragard T380 intrauterine device inserted.

DESCRIPTION: The patient was brought to the operating room and placed in the supine position, and given general anesthesia and intubated. She was placed in the dorsal lithotomy position and examination under anesthesia revealed a normal-sized anteverted uterus, no evidence of adnexal masses. She was then prepared and draped in the usual manner for simultaneous operative hysteroscopy and laparoscopy. These procedures were performed simultaneously after the bladder was catheterized and drained of about 200 cc of urine. A stab incision was made within the umbilicus through which a Veress needle was placed and 2 liters of carbon dioxide gas infused. Laparoscopic trocar and sleeve were inserted. Eventually a secondary puncture was created above the symphysis pubis. Vaginally a speculum was inserted into the vagina uterine cavity was explored. The scope was inserted a few centimeters into the endocervical canal into the lower uterine segment and was met with a wall of dense adhesions. Using blunt probes and flexible and rigid scissors, a cavity was eventually created and the limits of the uterotubal ostium or the cornua were determined by the use of a blunt probe, visualizing the movement of the probe in the cornual region of the uterus through the laparoscope, passed through the umbilicus. The left fallopian tube was actually cannulated with a Miles Novy cannula. Dye spill from the left tube was observed. Following the creation of the uterine cavity. Adhesions were dense and the procedure was involved. A Paragard T380 IUD was inserted and the position within the cavity verified by reinsertion of the hysteroscope.

Laparoscopically the uterus appeared to be normal in size. An old perforation site near the right cornua was identified. The left ovary was normal in size, oval in shape, white in coloration. Smooth surface was apparent. No adhesions or lesions were noted. The right ovary was normal in size, oval in shape, white in coloration. No adhesions or lesions noted. The left tube was normal in length, normal surface appearance, normal in size. The fimbria were delicate. As previously mentioned, this tube was cannulated and dye spill was seen. No adhesions or lesions noted. The right tube was normal in length. Normal surface appearance. Normal in size. This tube was not cannulated. The fimbria were delicate. No dye spill was seen. No adhesions were noted.

Following the procedure, the pelvis was irrigated. Hemostasis was found to be complete. Instruments were removed. Carbon dioxide gas was expelled. Incisions were closed with 4-0 Vicryl. The patient was reversed from anesthesia, extubated and transferred to the recovery room in satisfactory condition. She will receive Premarin therapy for the next morning prior to removing the IUD.


The patient was taken to the operating room. After adequate spinal anesthesia, was prepped and draped in the usual manner for cesarean section.

A Pfannenstiel incision was made taken down to the level of the rectus fascia. The fascia was incised and the incision was extended. The peritoneal cavity was bluntly entered and the incision was extended. The bladder flap was created and a bladder blade was placed.

A low transverse incision was made into the uterus. The vertex was elevated and noted to be direct occiput-posterior. The nasopharynx and oropharynx were suctioned, and the delivery of the infant was completed. The cord was clamped and cut, and the baby was handed to the pediatricians in attendance.

The infant received Apgar scores of 9 at one minute and 10 at five minutes. The placenta was delivered. The uterus was delivered through the incision. The incision was closed with two layers of 1-chromic suture, the first in a locking fashion and the second imbricating the first. Hemostasis was noted.

The abdomen was thoroughly irrigated and suctioned of all irrigation and blood clots. The bladder flap was closed with a running suture of 2-0 chromic. The uterus was returned to the abdominal cavity. The parietal peritoneum was closed with a running layer of 2-0 chromic suture. The fascia was closed with 0 Dexon suture. The skin was closed with skin staples.


Pubovaginal sling, cystoscopy, and suprapubic catheter placement.










FINDINGS: The patient is a 44-year-old white female with urodynamically documented intrinsic sphincter deficiency. Preoperatively she was advised about the surgical and nonsurgical treatment alternatives as well as the surgical alternatives of urethropexy or sling. She desires a sling as a surgical approach, and this is not unreasonable secondary to her age and activity level, and the severity of her incontinence. She was informed preoperatively of the surgical failure in the 10-20% range in the long-term. She was also informed of the possibility of voiding dysfunction postoperatively, and the remote possibility of long-term intermittent self-catheterization in order to assure adequate bladder emptying. The possibility of urge incontinence was also discussed. Other risks of the procedure including but not limited to death, anesthesia complications, need for blood transfusion, infection, and damage to surrounding structures including fistula formation, were also discussed. We discussed sling material and my recommendation was cadaveric fascia. We discussed the fact that this is human tissue and does carry with it a minimal but present risk of infectious complications including HIV and hepatitis, although this is felt to be minimal.

FINDINGS: A mobile uterovesical junction with minimal other pelvic organ prolapse. The surgery was technically challenging secondary to the patient's habitus.

DESCRIPTION OF PROCEDURE: Following the successful administration of general anesthesia, the patient was placed in the dorsal lithotomy position using Allen Universal stirrups. She was prepped and draped in the usual sterile fashion. A scalpel was used to create a transverse suprapubic incision. This was carried down through the subcutaneous fat to the rectus fascia. Hemostasis was assured with cautery.

Attention was turned to the anterior vaginal wall. A Foley catheter was placed to aid in identification of the urethra and uterovesical junction. The vaginal epithelium underlying the urethra was injected with 1% Xylocaine with epinephrine and incised with a scalpel. Sharp dissection was used to mobilize the vaginal epithelium off the underlying fascia. This was taken up to the Space of Retzius. The Space of Retzius was then entered sharply bilaterally. Hemostasis was assured with a combination of cautery and interrupted figure-of-eight sutures of 2-0 Vicryl.

The sling material was then prepared with packing on either side of the dissection. A strip of cadaveric fascia was incised for its width, approximately 2.5-3.0 cm. Two strips were taken from the one piece of cadaveric fascia that was available. This was overlapped over approximately 6 cm and tacked at each of the corners with interrupted sutures of CV-2 Gore-Tex. One side was colored so as to not twist the sling during placement. The pack was removed. Bleeding was minimal from the dissection sites.

At this point, using a finger from above and uterine packing forceps from below, the uterine packing forceps were placed first through the left and then through the right aspects of the dissected area in the Space of Retzius. This was placed to the fascia which was incised with a scalpel. The cadaveric fascia was brought down through the right incision and a suture was brought down through the left, which was attached to the other end of the cadaveric fascial sling, and was brought up to the fascia on that side as well. These ends were held with hemostats.

A series of four interrupted sutures of 2-0 PDS were then used to tack the sling at the UVJ and down the urethra to minimize the risk of the sling rolling under the urethra. These were tacked to the fascia and tied down where they were placed. The sling was under minimal tension under the urethra. In fact, a tonsil clamp could easily be slid between the fascia and the urethra.

Attention was turned above and the sling arms were tacked using a series of four sutures of CV-2 Gore-Tex on either side. Generous purchases of the cadaveric fascia were taken. This was tacked in the anterior rectus fascia. After these were all tied down, attention was again turned below. The sling was well positioned but not under any tension from the urethra. The subcutaneous tissue was frequently and copiously lavaged with antibiotic-containing solution from the VitalView suction device as was the vaginal aspect of the incision.

At this point, the fat was closed over the sling arms with a running-locking suture of 2-0 Vicryl. The bladder was then inspected with a cystoscope. The urethra was normal. There was no evidence of any trauma to the urethra or bladder. The urine was clear. Both ureters were identified and found to be functioning normally, spilling indigo carmine dye which had been previously given by the anesthesiologist. The bladder was then distended with 400 cc D-10. A suprapubic catheter was inserted through a separate stab wound in the anterior abdominal wall and inserted under direct visualization. This was affixed by inflating the balloon.

The skin was then closed from above with staples after hemostasis was assured in the subcutaneous tissue. The subcu was lavaged again with antibiotic-containing solution. The vaginal epithelium was closed with 2-0 Vicryl in a running-locking fashion. One small tear of the vaginal epithelium on the distal aspect of the incision on the left was sutured with an additional figure-of-eight suture of 2-0 Vicryl. Hemostasis was assured. The vagina was packed. The suprapubic tube was draining well. The patient was then taken to the recovery room in stable condition with the IV infusing well and the suprapubic tube draining well.

Repeat lower-segment transverse cesarean section.

1. Intrauterine pregnancy at 39-5/7 weeks gestation.
2. Arrest of second stage of labor and descent.
3. Rule out abruption versus uterine dehiscence.

1. Arrest of descent.
2. Left uterine artery laceration.

TITLE OF SURGERY:  Repeat lower-segment transverse cesarean section.

ANESTHESIA:  Epidural.


DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room after her epidural, preparation, and Foley had been performed. The abdomen was prepped and draped and tested for analgesia. When found to be adequate, a repeat low-abdominal Pfannenstiel incision was made with the first knife and carried down to the fascia with a second knife. The fascia was cleared of subcutaneous tissue. Bleeding points were clamped with hemostats and Bovie coagulated. The fascia was incised in the midline and extended laterally with curved Mayo scissors. Kocher clamps were placed on the fascial edge, first anteriorly and then superiorly.

The rectus muscles were separated by sharp dissection. A 5-yard roll was placed over the superior Kocher clamps and placed over the head of the table for retraction. The rectus muscles were divided in the midline by sharp dissection. The parietoperitoneum was grasped with hemostats and carefully entered with a scalpel, and the incision extended with Metzenbaum scissors. The bladder blade was inserted. The visceroperitoneum was grasped with smooth pickups, entered with Metzenbaum scissors, and extended laterally. The bladder flap was created by gentle blunt dissection and placed behind the bladder blade. The lower uterine segment was noted to be quite thin; it was carefully incised with a scalpel and extended laterally with bandage scissors.

A living female infant was delivered from the vertex right occipitotransverse position. The head was noted to be wedged into the pelvis but was easily elevated with a hand. The baby was suctioned and cried immediately, and was handed to the pediatric team in attendance. There was some blood in the intrauterine cavity but no evidence of a dehiscence or an abruption.

The placenta was delivered manually. The uterus was explored with a wet lap sponge and found to be clear of membranes. There was marked bleeding coming from the laceration of the left uterine artery. The angles of the incision were sutured first with #1 chromic catgut suture; however, the laceration was noted to be lateral to the initial placement and a repeat angled suture was placed. The first layer of uterine closure was with running-locking #1 chromic catgut suture. The second layer was with imbricating #1 chromic catgut suture. An interrupted #1 chromic was also placed at the left angle to control hemostasis. The second layer of uterine closure was imbricating #1 chromic catgut suture. Hemostasis was carefully checked and found to be satisfactory. The bladder flap was closed with a running 2-0 chromic catgut suture. The fallopian tubes and ovaries were inspected and found to be normal bilaterally.

After correct lap and instrument counts, the peritoneum was closed with a running 2-0 chromic catgut suture. The rectus muscles were approximated in the low midline with an interrupted #1 chromic catgut suture. The Kocher clamps and 5-yard roll were removed. This fascia was closed with two running 0-Vicryl from lateral to midline. The subcutaneous tissue was approximated with interrupted 2-0 plain catgut. The scar on the lower incision of the skin was removed with Allis clamps, elevating it and excising it with a scalpel. Bleeding points were Bovie coagulated.

The subcutaneous tissue was approximated with 2-0 plain catgut. The skin was closed with staples. Urinary output was adequate and blood-tinged. The patient left to the recovery room in good condition.

OPERATIVE REPORT -Laparoscopic Tubal Ligation


Preoperative Diagnosis:  
Postoperative Diagnosis :  

Assistant Surgeon:  
Estimtaed Blood Loss:  
Total fluids:  
Urine output: 

Multiparity desires permanent sterilization.  
Bilateral tubal ligation, Falope rings, electrocautery,electrocoagulation 
Resident, MD  
General/ epidural/spinal  
100cc ,clear 

Findings:Normal uterus, ovaries and tubes bilaterally

Indications:28 y/o G3, P3 who desires permanent sterilization. The patient was consented after informing the patient of the risk of hemorrhage, infection, and the additional risks: Failure of procedure -7.5: 1000 risk with partial salpingectomy or unipolar coagulation. 52:1000 to 54:1000 with bipolar coagulation or clip procedures Risk of ectopic gestation 1.2:1000 procedures with partial salpingectomy ,32 :1000 with bipolar tubal coagulation.


General anesthesia was obtained without difficulty. The patient was examined under anesthesia and found to have a small anteverted uterus. She was placed in dorsolithotomy position, prepped and draped in usual sterile fashion. A bivalve speculum was placed in the vagina and the anterior lip fof the cervix was grasped with a single toothed tenaculum .A (HUMI,Kroner,Hulka) manipulator was placed. The speculum and tenaculum were then removed from the vagina. Attention was turned to the patient's abdomen where a 10mm skin incision was made into the infraumbilical fold . A (Veress,Scwimmer-Bell) needle was inserted through the incision without difficulty and a pneumoperitoneum was obtained to a final pressure of 15 mm Hg (obese patients may require a pressure of 20-25 mm Hg). The needle was removed , and a 10 mm trocar with sleeve was advanced without difficiculty into the abdomen. Intrabdominal placement was confirmed by laparoscope. A survey of the patient's pelvis and abdomen revealed the above findings. For second trocar- (A 5 mm skin incision was also made 2 cm above the pubic symphysis, and a 5 mm trocar with sleeve advanced through it under direct visualization. ) The ( Falope ring applicaor, Kleppinger electrocoagulator) was advanced through the instrument channel of the laparoscope (or inferior trocar) The patient's left tube was identified, followed out to the fimbriated end and grasped approximately 4 cm from the cornual region. The (Falope ring, Kleppinger) was then applied with a good knuckle of tube noted and good blanching at the site of application for a distance of 3 cm.. There was no bleeding on the mesosalpinx. The Falope ring applicator was reloaded and (omit italics for electrocoagulation)the patient's right tube was manipulated in a similar fashion with easy application of the Falope ring. All instruments were removed from the abdomen under visualization, and the incision(s) were repaired with 3-0 plain suture. The uterine manipulator was removed with no bleeding noted from the cervix. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct times two. She was taken to the recovery room in good condition.

Pathology: Segments of left and right tubes were sent for pathology.


Under satisfactory general anesthesia, Foley catheter was inserted in a sterile manner. The vagina was prepped with Betadine, the abdomen shaved as well as the pubic hair, and the patient was prepped and draped for a Pfannenstiel incision. This was carried down through the skin, the subcutaneous tissue. The fascia was incised transversely. The rectus muscles were separated and the peritoneum entered in a vertical manner. O'Sullivan-O'Connor retractor was utilized. Four lap pads were placed at the pelvic brim to retract the bowel out of the pelvis, and also to put a lap pad under each blade of the retractor.

Visualization of the pelvis showed a normal small uterus, normal tubes and ovaries. The round ligaments were bilaterally clamped, cut and suture ligated. The infundibulopelvic ligaments were bilaterally clamped, cut and suture ligated. The uterine blood vessels were bilaterally clamped, cut and suture ligated. A 0 Vicryl was used throughout the case. Approximately four bites were necessary on either side of the cervix to go down and take the cardinal ligament and paracervical tissue to reach the vaginal vault, which were clamped, cut and suture ligated bilaterally.

On reaching the vaginal vault, the vagina was entered anteriorly and the specimen removed by cutting circumferentially about the cervix. The specimen thus consisted of uterus, cervix, tubes and ovaries.

Angle sutures were placed bilaterally, incorporating the posterior vaginal mucosa, the anterior vaginal mucosa and the cardinal ligament stump. The hemostatic running locking suture was then placed around the vaginal vault. There was a small opening for the vagina, and it was decided that no additional narrowing was necessary. One figure-of-eight suture was needed in the stump of the right cardinal ligament near the uterine stump. This made for good hemostasis.

The pelvis was then reperitonealized utilizing 2-0 Vicryl with a locking suture, in such a manner that the infundibular and round ligament stumps were placed in a retroperitoneal manner. Having closed the peritoneum, the pelvis was irrigated with saline and then attention directed to closure of the abdomen.

It was noted at this point that the appendix was visible and appeared normal.

The peritoneum was closed with a running locking suture of 3-0 Vicryl. The rectus muscle approximated with a running locking suture of 2-0 Vicryl. The fascia was closed with two separate running locking sutures of 0 Vicryl starting laterally and tied separately in the midline. The wound was irrigated with Betadine. The subcutaneous tissue approximated with a running locking suture of 2-0 Vicryl and the skin closed with staples.

Total abdominal hysterectomy with a bilateral salpingo-oophorectomy (TAH & BSO)

1. Left ovarian mass.
2. Elevated ca-125 level.

1. Bilateral ovarian endometriomas.
2. Pelvic endometriosis.
3. Myomata uteri.
4. Left ureteral occlusion.

1. Examination under anesthesia.
2. Exploratory laparotomy.
3. Lysis of adhesions.
4. Resection of left ureter.
5. Extrafascial hysterectomy.
6. Bilateral salpingo-oophorectomy.

ANESTHESIA:  General endotracheal anesthesia.

INDICATIONS:  The patient is a 57-year-old female who presented with bilateral ovarian masses and an elevated CA-125 level. She was taken to the operating room for definitive surgery.

DESCRIPTION OF PROCEDURE:  The patient was placed under general anesthesia in the dorsal lithotomy position. Examination revealed a large left 15-cm ovarian mass which appeared fixed, and fullness in the right adnexa. Fortunately, neither nodularity nor thickness was appreciated. The vagina was prepped and a Foley catheter inserted. The patient was placed in the supine position and her abdomen was prepped and draped.

A right paramedian incision was made from the symphysis to the umbilicus and was carried down to the anterior and posterior sheaths until the peritoneal cavity was entered. Peritoneal washings were then taken. Exploration of the upper abdomen revealed two normal kidneys and a smooth right lobe of the liver from the lateral margin to the ligamentum teres. There were at least two stones palpable in the gallbladder, at least 1 cm in diameter. Both diaphragmatic surfaces were smooth. The large and small bowel were grossly normal. Retroperitoneally, there were no enlarged or suspicious periaortic nodes from the level of the renal vessels to the bifurcation of the iliacs.

Within the pelvis, there seemed to be an enlarged uterus with a right ovarian endometrioma about 5 cm in diameter. There was a 14-cm semisolid fixed left adnexal mass which was adherent to the posterior wall of the uterus, the sigmoid colon, the posterior peritoneum, and the parietoperitoneum. As previously discussed with the patient, if neither ovary could be saved in this case with bilateral endometriomas, and given the myomata uteri, the surgical plan was to perform hysterectomy and bilateral salpingo-oophorectomy. Therefore, we began the surgery by freeing up the anterior attachments of the large left adnexal mass to the sigmoid colon.

We then went to the lateral pelvic side walls and were eventually able to find the round ligaments; these were identified and singly clamped and ligated with 0- Vicryl. We then developed a plane of the pubovesical cervical fascia, thereby freeing the bladder from the underlying cervix and vagina. Indigo carmine was given intravenously and was eventually seen to exit in the Foley catheter with no intraperitoneal or retroperitoneal spillage.

To facilitate dissection of the large left ovarian mass, we dissected the left ureter which was intimately adherent to the mass and occluded during its length. Therefore, a ¼-inch  Penrose drain was placed around the left ureter. This was completely dissected down to its entrance into the bladder. This then allowed us to find the infundibulopelvic pedicle from the left mass, and to doubly clamp and ligate this with 0-Vicryl. We continued to free up the large left pelvic mass and came to the uterine arteries on both sides. We were able to doubly clamp the uterine arteries. We then continued with single clamping of the cardinals, and then opened up the rectovaginal septum so we could cross-clamp the uterosacral ligaments. In this manner, we were eventually able to completely perform extrafascial hysterectomy, and the uterus, large left adnexal mass, right ovarian endometrioma, and tubes were removed as a single specimen. The endometrioma was then opened. As expected, it was completely filled with dark chocolate fluid.

Angled sutures were placed in the vagina with 0-Vicryl and reinforced. The cuff itself was then closed with continuous running 0-Vicryl suture. There were a number of bleeders in the pelvis which we then controlled with clips and hot cautery. On account of the patient's weight, the difficulty of the surgery, and the persistent small bleeders, it was elected to placed a 19-mm J-Vac drain deep in the cul-de-sac and to bring this out through the right lower quadrant. The pelvis was then copiously irrigated. When hemostasis was seen to be excellent. generous portions of Gelfoam were placed over all raw peritoneal surface areas.

Following correct lap pad, sponge, instrument, and needle counts, attention was turned to closure of the abdomen. Then 0-Prolene was used to place a row of interrupted horizontal mattress sutures through the anterior sheath. The anterior sheath itself was closed with two continuous running #1 PDS sutures starting inferiorly and superiorly and meeting in the lower 1/3 of the incision. The Prolene sutures were then tied. The subcutaneous tissue was then copiously irrigated with Ringer's, and the subcutaneous tissue approximated with interrupted 2-0 Monocryl sutures. The skin edges were approximated with 4-0 Monocryl subcuticular suture reinforced with 1/2" Steri-Strips and benzoin.

Estimated blood loss was 600 cc. Fluid replaced was 3400 cc crystalloid. Drains included a Foley catheter draining blue urine, and a cul-de-sac J-Vac. There were no complications The patient was sent to the recovery room in satisfactory condition.

Transurethral resection of the bladder tumor.

Bladder carcinoma.

Bladder carcinoma.


DESCRIPTION: The patient was taken to the operating room and after induction of anesthesia and the administration of intravenous antibiotics, he was prepared and draped in the usual relaxed dorsal lithotomy position.

The anterior urethra was sounded to 30-French, and then the Iglesias resectoscope was placed and cystopanendoscopy was performed with the results noted below. The urethra was within normal limits. The outlet nonocclusive bladder capacity was adequate.

The orifices were normal in position and morphology, and the left orifice was adjacent to a large fungating bladder carcinoma which was obviously necrotic. The tumor extended to the entire surface of the left lateral wall and was sequy resected into deep muscle using the Iglesias resectoscope. No other lesions were identified. A separate biopsy of the prostatic urethra was obtained. Electrocardiogram was used to achieve hemostasis. The chips were removed and the bladder was once again inspected and found to be free of evidence of injury, and the ureteral orifices were intact at the conclusion of the procedure. No evidence of perforation was identified. The scope was withdrawn and a 24-French 30-cc bag, three-way Foley catheter was placed to continuous bladder irrigation with clear efflux of urine noted. The patient was taken to the recovery room in stable condition, having tolerated the procedure well.



With the patient under general anesthesia in the lithotomy position, she was prepped and draped in the usual manner. Bimanual examination was performed with the findings as noted above.

Labia minora were sutured to the labia majora, using silk sutures on each side. A weighted speculum was placed in the posterior wall of the vagina, and the cervix was grasped bilaterally with two tenacula.

An incision was made circumferentially around the cervical vaginal junction, after which the cervical vaginal mucosa was pushed upward. An Allis clamp was then placed between the uterosacral ligaments and an opening was made into the cul-de-sac and widened. Figure-of-eight sutures of 2-0 Vicryl were taken to approximate the peritoneum to the posterior vaginal mucosa. In order to control oozing, the middle suture was held long. The right and then the left uterosacral ligaments were doubly clamped. The left uterosacral ligament was then suture ligated with a suture also being placed in the vaginal mucosa on its respective side in order to form a new fornix of the vagina.

The more distal suture was placed on the uterosacral ligament distally, and this was held long. This was repeated on the right side. The right and the left uterine pedicles were then doubly clamped, cut and suture ligated with sutures of 0 Vicryl. The weighted speculum was then placed in the cul-de-sac. A finger was inserted in front of the uterus to a level at the vesicouterine junction in order to ascertain this location. This area was then dissected free. Both bladder pillars were clamped, cut and suture ligated with suture of 2-0 Vicryl. An opening was then made in the uterovesical peritoneum.

The uterus was then delivered posteriorly, after which double clamps were placed across the right medial portion of the right broad ligament, ovarian ligament, middle portion of the fallopian tube, and another clamp was placed across the lower portion of the broad ligament, including the round ligament. This too was doubly clamped, after which the right side of the uterus was freed.

Each pedicle was doubly suture ligated with sutures of 0 Vicryl. The distal suture on the region of the round ligament was held long. This was then repeated on the left side. Oozing was noted to be present, which was controlled with figure-of-eight sutures of 2-0 Vicryl until hemostasis was noted to have been obtained.

The ovaries were palpated and found to be normal. Lap, sponge, instrument and needle count were reported to be correct.

The peritoneum was closed with a pursestring suture of 2-0 Vicryl, after the weighted speculum had been removed. Ties on the uterosacral ligaments were tied together as well as ties across the round ligaments on each side. These were then tied to each other, so that there were contralateral and ipsilateral tying. In this way, the pedicles were exteriorized and hemostasis was noted to be obtained.

Two Allis clamps were then placed at the base of the cystocele. Another Allis clamp was placed at the apex of the cystocele. The anterior vaginal mucosa was then incised at the midline to the Allis clamp at the apex of the cystocele. The vaginal mucosa was then dissected by sharp and blunt dissection from the underlying tissue. Bleeding was encountered laterally, which was controlled using figure-of-eight sutures of 2-0 Vicryl. A series of mattress sutures of 2-0 Vicryl were then taken in order to imbricate the cystocele. Two Kelly plication sutures of 2-0 Vicryl were then taken, and this gave good support to the urethra. A Foley catheter was then inserted into the urethra and urine was noted to be clear. The catheter was inserted easily without any evidence of obstruction.

Excess anterior vaginal mucosa was then excised, after which the anterior vagina was approximated using interrupted sutures of 2-0 Vicryl. Hemostasis was noted to have been obtained.

Attention was then turned to the posterior wall. Two Allis clamps were placed at the mucocutaneous junction in the region of the fourchette, and another clamp was placed at the apex of the rectocele. The tissue between the distal two clamps and the region of fourchette was excised, and carefully measured so that the introitus would be a three finger introitus. The posterior vaginal mucosa was then incised in the midline by sharp and blunt dissection. The posterior vaginal mucosa was then dissected to the level at the Allis clamp at the apex of the rectocele. The posterior vaginal mucosa was dissected with blunt and sharp dissection from the underlying tissue. The rectocele was then imbricated using mattress sutures of 2-0 Vicryl. Two sutures of 0 Vicryl were then taken in the levator ani musculature. The excess posterior vaginal mucosa was then excised, after which the posterior vaginal mucosa was approximated using interrupted sutures of 2-0 Vicryl. The stitches in the levator ani muscle were then tied in the midline, after which the closure of the posterior vaginal mucosa was continued using 2-0 Vicryl. The perineal muscles were then approximated in the midline in layers, using 2-0 Vicryl, after which the perineal skin was approximated using interrupted sutures of 2-0 Vicryl.

Hemostasis was noted to be present. Lap, sponge, instrument and needle count were reported to be correct. A finger was inserted into the rectum, and no stitches were present in the rectum. A two-inch iodoform gauze was packed into the vagina. The Foley catheter was noted to be draining clear at the close of the procedure.



The patient was prepped and draped and placed in the lithotomy position.

Examination under anesthesia revealed long, closed posterior cervix, normal size uterus, anteverted, a normal adnexa on the right, and a left adnexal mass about 5-cm.

Foley catheter was placed into the bladder, draining clear yellow urine, and the vaginal speculum was inserted in order to visualize a normal cervix, which was grasped anteriorly. A HUMI probe was put into the uterus at 7-cm.

The surgeons changed gloves and approached the abdomen. At this point, Veress needle was inserted in an infraumbilical incision and 3.4 liters of carbon dioxide gas created a pneumoperitoneum. At this point, a 10-mm trocar was inserted through the pneumoperitoneum, and we immediately noted that we were in an omental space. The trocar was removed, and a VersaPort was put in. Under VersaPort visualization, the trocar was inserted and we noted that we were in the peritoneal cavity.

At this point, the liver was examined and found to be normal. The gallbladder was found to be normal. Attention was turned to the pelvic cavity. Immediately noted was a normal size uterus, and a very large, 5 to 6-cm, ampullary tubal pregnancy.

We then placed a 5-mm and 10-mm port in the left and right lower quadrants, through which inserted our instruments.

The surgical assistant was able to raise up the ectopic pregnancy, while I, using the Davol and electrode needle, cut along the mesenteric edge. Immediately, the ectopic pregnancy started pumping furiously and immediately about 200 cc of blood were lost. We quickly placed a 12-mm trocar in and a GIA stapler in the right lower quadrant.

At this point, the GIA stapler on the right side was grasped by the assistant, while I grasped the tubal pregnancy on the left side; raising it up, the assistant was able to use the GIA stapler and clip the ectopic pregnancy. Immediately, the bleeding stopped; however, by this time, we had about 500 cc of blood in the peritoneal cavity.

We then had to remove the entire tube at the ampullary end; however, upon examination, we noted that the fimbria of this tube were completely enmeshed into the ectopic pregnancy, and there would not have been a chance to do a salpingostomy. The ectopic pregnancy was dropped into the Endo-Sac and removed and sent to pathology.

At this point, copious irrigation was performed in order to remove all the clots and clearly examine the suture side of the left ectopic pregnancy.

Chromopertubation revealed that the suture line was completely clean and hemostatic. It also revealed that there was complete tubal occlusion of the right tube, showing a completely clogged fimbrial portion. The ovaries were noted to be normal and the uterus was noted to be normal.

At this point, we completely removed all the clots and removed the instruments in order to remove the entire pneumoperitoneum. All the gas was removed. We placed 0 Vicryl sutures into the fascial areas of the infraumbilical and the right lower quadrant and 4-0 undyed Vicryl closed all the skin incisions.

At this point, the HUMI and the Foley catheter were removed, and the patient was taken to the recovery room in stable condition.

Hysteroscopy and dilatation and curettage.

Dysfunctional uterine bleeding.

Dysfunction uterine bleeding.

Local sedation.

DESCRIPTION: The patient was brought to the operating room and placed in the supine position and given intravenous sedation. She was placed in the dorsal lithotomy position and examined. Examination revealed an enlarged uterus with a suspected posterior wall leiomyomata in the cul-de-sac. There was no evidence of adnexal masses. The rectovaginal examination was confirmatory.

The patient was then prepared and draped in the usual manner for hysteroscopy and possible dilatation and curettage. A Wolf carbon dioxide hysteroscope was utilized. The cervix was inspected and found to be normal. A paracervical block was placed with a total of 18 cc of 1% Xylocaine plain, 9 cc in each lateral paracervical area. The endocervical canal was normal. The uterine cavity: The right and left uterotubal ostia and cornua were identified. They appeared normal. The anterior, posterior and lateral walls were smooth, although the posterior wall was somewhat extrinsically compressed. No lesions were noted. The hysteroscope was reinserted to verify sampling of the cavity. All instruments were then removed. Tissue specimen was submitted to pathology.


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