OPERATION PERFORMED: Laparoscopic vaginal hysterectomy.
PREOPERATIVE DIAGNOSES:
- Postmenopausal bleeding.
- Menorrhagia.
- Right ovarian cyst.
POSTOPERATIVE DIAGNOSES:
- Postmenopausal bleeding.
- Menorrhagia.
- Right ovarian cyst.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia by way of oral endotracheal tube intubation.
FINDINGS: A prominent size uterus with essentially a normal-appearing left ovary with a relatively small cystic area. Evidence of previous left oophorectomy as well as blunted fallopian tubes.
FLUIDS: 2200 mL of crystalloid.
ESTIMATED BLOOD LOSS: 75-100 mL.
URINE OUTPUT: 200 mL.
COMPLICATIONS: None.
SURGICAL COUNT: Correct.
DRAINS: Foley to straight drain.
SPECIMENS: Morcellated uterus, right ovary, and fallopian tubes to pathology.
DISPOSITION: Patient to the recovery room.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the dorsal supine position for laparoscopic vaginal hysterectomy. She was then placed on general anesthesia and intubated. From there, she was placed in the dorsal lithotomy position, and the bladder was drained of approximately 100 mL of clear urine. She was then prepped and draped in usual sterile fashion. She was examined under anesthesia with notation of an anteverted uterus prominent and mobile. There were no adnexal masses.
With these findings noted, the speculum was placed into the vagina exposing the cervix. The cervix was then grasped with a single-tooth tenaculum and a Hulka tenaculum was then advanced. All other instruments were then removed. With the patient in Trendelenburg position, attention was turned to the abdomen. An infraumbilical incision was then performed, through which the Veress needle was advanced while the anterior abdominal wall was elevated.
Once entry was confirmed with an opening pressure about 10 mmHg, the abdomen was insufflated with CO2 gas to approximately 2 liters. The Veress needle was removed and replaced with a 5 mm port under direct visualization. A second puncture site was then placed two fingerbreadths above the symphysis pubis in the midline through which another 5 mm port was advanced.
With the patient in Trendelenburg position, the following findings were noted: A relatively prominent-appearing uterus. The right ovary appeared relatively normal in appearance with notation of a small ovarian cyst. The left ovary was surgically absent. The fallopian tubes on either sides were somewhat blunted. The appendix was visualized. The liver’s edges were normal. There was nonspecific bowel appearance noted. With these findings noted, two additional puncture sites were placed lateral to the obliterated umbilical artery with 10 mm ports passed under direct visualization.
With these findings noted, the round ligament was opened on the right side with a tripolar instrument coagulating and incising the ligament. Using the Endoshears, the uterovesical fold incision was then extended towards the midline in a curvilinear fashion. The sidewall was also opened with the bipolar Endoshears. The sidewall was dissected until the ureters were isolated and coursed to the bladder as well as the infundibulopelvic ligament. With the ureters clear, the right ovary was grasped with atraumatic grasper. The infundibulopelvic ligament now exposed, this was then grasped with the tripolar instrument, coagulated and cut.
Subsequently, the utero-ovarian ligament was grasped with the instrument again, coagulated and cut. The broad ligament down to the level of the uterine vessels were subsequently coagulated and cut. Attention was then turned to the opposing side; the left round ligament was identified, placed on traction with an atraumatic grasper, subsequently coagulated and cut. The Endoshears were used to further incise the uterovesical fold towards the midline as well as the sidewall on the left side. The ureter was subsequently dissected free, and with this finding noted, we proceeded to remove the left fallopian tube beginning at a small amount of omental adhesions at this tip, proceeding down the broad ligament to the level of the uterine arteries, coagulating and cutting the pedicles at the level of the uterine arteries. The arteries on either side were then skeletonized again with notation of the ureter, which incidentally on the left side coursed towards the anterior portion of the bladder. The uterine vessels were then double coagulated and subsequently incised with the tripolar instrument. We proceeded down to the level of the uterosacral ligaments, which were also coagulated and cut at the base.
The bladder was dissected anteriorly by both sharp and blunt dissection. Furthermore, the bladder was insufflated with normal saline to help determine its secure margin and once reassured of its displacement from the lower uterine segment, initially using the Endoshears the upper uterine segment was then incised. However, secondary to the difficulty and firmness of the cervix, we proceeded to use the harmonic scalpel. Using a harmonic scalpel, the specimen was subsequently resected free with minimal difficulty; however, either due to the shortness of the cervix or the angling down on the harmonic scalpel, it was apparent that the complete cervix had been removed, and with this finding noted and the specimen free, the right port was replaced with the morcellator.
Using the large tenaculum, the uterus was grasped and subsequently guided to the morcellator. The uterus was subsequently shredded with the morcellator and the pieces were removed and to be sent to pathology. The right ovary was also removed. This was sent separate with the opposing fallopian tube but all the specimens removed and remaining fragments of the uterus additionally removed. The pelvis was irrigated until clear. Unfortunately, because of the extent of the cervical re-movement, the upper vagina was opened, thereby making it difficult to keep the gas in place. A wet towel was then placed into the vagina to help maintain the pneumoperitoneum.
Subsequently, the pelvis was irrigated until clear. Because of the extent of the opening of the vaginal cuff, it was decided not to leave it open to close by secondary intention. We therefore moved to the vagina. A Graves speculum was placed into the vagina, allowing the exposure of the vaginal cuff, which was then closed with interrupted 0 Vicryl suture. Hemostasis noted.
Attention was then returned to the abdomen. The abdomen was then reinflated, irrigated with normal saline until clear. At the procedure’s end, we left 300 mL of normal saline in the pelvis for adhesion prevention subsequently with hemostasis noted. The abdomen was then deflated. All trocars were removed under direct visualization. The incisions were closed using 0 Vicryl to approximate the fascia from the larger ports. This was made feasible secondary to the patient’s small size. The edges were grasped with Allis clamps to secure adequate closure. Skin edges were approximated with 4-0 Prolene in a subcuticular fashion. Soaked Kerlix was also placed into the vagina. It is of note, prior to the procedure beginning, the patient was given 2 grams of Ancef, which will be repeated 8 hours post surgery. The incisions were dressed appropriately. The patient was subsequently returned to the dorsal supine position. Anesthesia was reversed. She was extubated and taken to the recovery room in stable condition at the conclusion of the laparoscopic vaginal hysterectomy.
