HOME > operative reports > Obstetrics/Gynecology

operative reports

Obstetrics/Gynecology

PROCEDURE: Bilateral Laparoscopic Tubal Ligations

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 3 L 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 g of Cefotan. The pneumoperitoneum and the instruments were removed under direct vision. The skin was closed with 3-0 Dexon and the HUMI removed.

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 1 minute and 10 at 5 minutes. The placenta was delivered. The uterus was delivered through the incision. The incision was closed with 2 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.

OPERATIVE 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, a Veress needle was inserted in an infraumbilical incision and 3.4 L 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 mL 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 mL 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 Endosac 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.

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. Then 4 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 4 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 2 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.

PROCEDURE: VAGINAL HYSTERECTOMY

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 2 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 2 clamps and the region of fourchette was excised, and carefully measured so that the introitus would be a 3-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 2-inch iodoform gauze was packed into the vagina. The Foley catheter was noted to be draining clear at the close of the procedure.