TITLE OF OPERATION:
Cystourethroscopy, left retrograde ureteropyelogram
and left dismembered pyeloplasty.
PREOPERATIVE DIAGNOSIS:
Left ureteropelvic junction obstruction.
POSTOPERATIVE DIAGNOSIS:
Left ureteropelvic junction obstruction.
ANESTHESIA:
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.
PREOPERATIVE DIAGNOSIS:
Severe Asherman syndrome.
POSTOPERATIVE DIAGNOSIS:
Severe Asherman syndrome.
ANESTHESIA:
General endotracheal anesthesia.
PROSTHETIC DEVICE:
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.
PROCEDURE: PRIMARY LOW-FLAP CESAREAN SECTION
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.
PREOPERATIVE DIAGNOSES: INTRINSIC URETHRAL SPHINCTER DEFICIENCY.
POSTOPERATIVE DIAGNOSES:
1. INTRINSIC URETHRAL SPHINCTER DEFICIENCY.
2. INADEQUATE BLADDER EMPTYING.
TITLE OF SURGERY:
1. CADAVERIC FASCIAL PUBOVAGINAL SLING.
2. CYSTOSCOPY.
3. INSERTION OF SUPRAPUBIC CATHETER.
ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.
ESTIMATED BLOOD LOSS: 500 CC.
FLUID REPLACEMENT: 3400 CC CRYSTALLOID.
CONDITION: STABLE.
URINE OUTPUT: 150 CC.
COMPLICATIONS: NONE.
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.
PREOPERATIVE DIAGNOSES:
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.
POSTOPERATIVE DIAGNOSES:
1. Arrest of descent.
2. Left uterine artery laceration.
TITLE OF SURGERY: Repeat lower-segment transverse cesarean section.
ANESTHESIA: Epidural.
ESTIMATED BLOOD LOSS: 1000 cc.
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
|
DATE OF OPERATION:
Preoperative Diagnosis:
Postoperative Diagnosis :
Procedure:
Surgeon:
Assistant Surgeon:
Anesthesia:
Complications:
Estimtaed Blood Loss:
Total fluids:
Urine output: |
01/01/95
Multiparity desires permanent sterilization.
Same
Bilateral
tubal ligation, Falope rings, electrocautery,electrocoagulation
Attending,MD
Resident, MD
General/ epidural/spinal
None
5cc
10cc
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.
Procedure:
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.
OPERATIVE PROCEDURE: TOTAL ABDOMINAL HYSTERECTOMY/BILATERAL SALPINGO-OOPHORECTOMY
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)
PREOPERATIVE DIAGNOSES:
1. Left ovarian mass.
2. Elevated ca-125 level.
POSTOPERATIVE DIAGNOSES:
1. Bilateral ovarian endometriomas.
2. Pelvic endometriosis.
3. Myomata uteri.
4.
Left ureteral occlusion.
TITLE OF SURGERY:
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.
TITLE OF OPERATION:
Transurethral resection of the bladder tumor.
PREOPERATIVE DIAGNOSIS:
Bladder carcinoma.
POSTOPERATIVE DIAGNOSIS:
Bladder carcinoma.
ANESTHESIA:
Spinal.
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.
PROCEDURE: VAGINAL HYSTERECTOMY
VAGINAL HYSTERECTOMY
ANTERIOR COLPORRHAPHY
KELLY PLICATION
OF THE URETHRA
POSTERIOR COLPOPERINEORRHAPHY
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.
OPERATIVE PROCEDURE:
VIDEO LAPAROSCOPIC SALPINGECTOMY
LYSIS OF ADHESIONS
CHROMOPERTUBATION
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.
PREOPERATIVE DIAGNOSIS:
Dysfunctional uterine bleeding.
POSTOPERATIVE DIAGNOSIS:
Dysfunction uterine bleeding.
ANESTHESIA:
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.
