TOTAL LAPAROSCOPIC HYSTERECTOMY

 

PREOPERATIVE DIAGNOSIS: ***

 

POSTOPERATIVE DIAGNOSIS: same

 

OPERATION: Total Laparoscopic hysterectomy, bilateral salpingo-oophorectomy

 

SURGEON: ***

 

ASSISTANT SURGEON: ***

 

ANESTHESIA: General

 

COMPLICATIONS: None

 

FLUIDS: *** cc crystalloid

 

ESTIMATED BLOOD LOSS: *** cc

 

URINE OUTPUT: *** cc draining via Foley

 

SPECIMEN: Uterus, cervix, both tubes and ovaries

 

INDICATIONS:

*** yo G***P*** with history of ***. She has a good understanding and has agreed to proceed with definitive surgical management with a laparoscopic hysterectomy, bilateral salpingo-oophorectomy. Risks and benefits were discussed and patient consented to the procedure.

 

FINDINGS: 

***Normal appearing, anteverted uterus with normal appearing tubes and ovaries bilaterally. Normal bowel, omentum, liver, gallbladder, appendix and peritoneal cavity survey. 

 

DRAINS: Foley catheter

 

DISPOSITION: PACU

 

CONDITION: Hemodynamically stable.

 

PROCEDURE:  

The patient was met in the pre-operative holding area where consents and procedures were reviewed and all questions answered. ***She was given pre-operative tylenol, gabapentin and heparin. She was brought to the Operating Room where SCD devices were placed on both calves, general anesthesia was induced and IV antibiotics were administered. Surgical time out was performed. The abdomen, vagina and perineum were prepped and draped. Atraumatic vaginal retractors were placed to identify the cervix and complete the examination. The cervix was grasped with a single tooth tenaculum. The cervix was easily dilated and the uterus sounded to *** cm. A *** Koh ring was placed around the cervix.  Then a *** cm RUMI cannula was placed in the uterine cavity without difficulty. A Foley catheter was placed in a sterile fashion.

 

A ***5 mm vertical incision was made in the umbilicus, and with the abdomen under anterior traction with two peri-umbilical towel clamps, a Veress needle was inserted into the abdominal cavity with the carbon dioxide on low flow. Immediate pressure drop to 0 mm and diffuse abdominal distention indicated intraperitoneal placement. The peritoneal cavity was then insufflated with carbon dioxide on high flow to maintain a pressure of 15 mm Hg throughout the case.  A ***5mm versistep port was placed through the umbilicus. An abdominal survey was performed. ***5mm ports were placed under direct visualization in the right and left lower quadrants. There was no injury to underlying viscera.

 

The ureters were then identified retroperitoneally, coursing well posterior to the ovarian vessels. The peritoneum was opened laterally to the IP ligament and the IP was cauterized and transected. With the uterus on upward traction, the round ligaments were isolated, cauterized and cut. The peritoneum was incised in planes lateral and parallel to the uterine vessels on both sides, and dropped posteriorly to the uterosacral ligaments. The vesico-uterine peritoneum was incised, and the bladder dissected from the cervix and upper vagina. The uterine vessels were then skeletonized bilaterally and coagulated and divided to the level of the cervical-vaginal junction, with each successive pedicle created medially to the previous to avoid ureteral injury. The vaginal balloon was insufflated.　With the bladder mobilized anteriorally and the rectum well away posteriorally, using the monopolar device, an incision was made in the anterior upper vagina at the level of the cervical-vaginal junction. The incision was continued circumferentially around the upper vagina with complete amputation of the specimen. The uterus, cervix, and bilateral fallopian tubes and ovaries were then removed en bloc transvaginally.

 

***The upper vagina was then closed vaginally with running 0 Vicryl, taking care to avoid bladder injury.  The upper vagina was intact and hemostatic and was re-examined internally via laparoscopy. The pelvis was irrigated and suctioned and was noted to be hemostatic. Both ureters were seen, actively peristalsing into the pelvis.

 

The laparoscopic instruments were removed and the skin incisions were closed with subcuticular stitches of 4-0 Biosyn. All sponge, needle and instrument counts were correct x3.  Anesthesia was reversed and the patient was taken to the PACU in a stable condition.