DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Symptomatic uterine fibroids.
2. Left ovarian dermoid cyst.
POSTOPERATIVE DIAGNOSES:
1. Symptomatic uterine fibroids.
2. Left ovarian dermoid cyst.
3. Severe endometriosis.
4. Endopelvic adhesions.
OPERATION PERFORMED:
1. Robotic total hysterectomy.
2. Left salpingo-oophorectomy with lysis of adhesions.
3. Cystoscopy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 150 mL.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and administered a general anesthetic. The patient was then placed in the dorsal lithotomy position and sterilely prepped and draped in the usual manner. A Foley catheter was placed in the bladder. A weighted speculum was placed in the vaginal vault.
A single-tooth tenaculum was placed in the anterior lip of the cervix, and the cervical os was dilated to #8 Hegar dilator. A RUMI uterine manipulator was then attached to the uterus with the cervical ring. The weighted speculum was removed from the vaginal vault. The single-tooth tenaculum was removed from the anterior lip of the cervix. Two sutures were placed on the lateral aspect of the cervix to be used as traction later in the case.
A horizontal supraumbilical incision was made with the scalpel and Veress needle was placed in the abdominal cavity. Through the Veress needle, carbon dioxide was infused until pseudo pneumoperitoneum was obtained. The Veress needle was then removed and the supraumbilical incision was extended. A 12 mm trocar and sleeve was then placed in abdominal cavity without difficulty. The trocar was removed and the robotic laparoscope was placed in the abdominal cavity.
The pelvic viscera were examined. The uterus was found to be diffusely enlarged with uterine leiomyoma. The left ovary was diffusely enlarged with a dermoid cyst. The right ovary appeared to be normal. There were adhesions in the posterior cul-de-sac. There were multiple implants of endometriosis noted. Local anesthesia was then instilled at the sites of all the ports prior to placing the Surgiports.
Two 8 mm Surgiports were then placed just inferior to the umbilicus and lateral to the rectus abdominis muscle bilaterally. These ports were put into the abdominal cavity under direct visualization. The assistant’s port was then placed just beneath the ribs in the left upper quadrant of the abdomen. The da Vinci robot was then backed with the Surgiports. In the left arm was placed a plasma kinetic device and the right with the hot scissors.
Due to the fact that there was a large left dermoid cyst on the left ovary, it was felt that the left ovary should be removed. The left infundibulopelvic ligament was then isolated, cauterized in 3 contiguous areas with the PK. The infundibulopelvic ligament was then cut. The left adnexa was then separated from pelvic side wall using PK and the hot scissors. The round ligament on the left was then cauterized and cut.
The left side of the vesicouterine peritoneum was then incised, forming the left side of the bladder flap. The left uterine vasculature was then isolated and cauterized. The right ovary appeared to be within normal limits, so it was felt it would be okay to leave it.
The right ovary was densely adherent to the posterior surface of uterus. These adhesions were carefully lysed using the hot scissors. The uteroovarian ligament was cauterized with the PK and then cut. The proximal fallopian tube was similarly cauterized with PK and cut with scissors. The round ligament was cauterized in 3 contiguous areas and cut with the PK.
The vesicouterine peritoneum on the right was then incised in elliptical fashion forming the right side of bladder flap. The bladder was pushed down off the lower uterine segment without difficulty. Uterine vasculature on the right was then cauterized.
The ring was identified anteriorly and an anterior colpotomy was performed. The uterine vasculature was cauterized bilaterally as the colpotomy was extended.
After completely circumscribing the scissors from the vaginal cuff, the uterus and left adnexa were then delivered through the vagina. The vaginal cuff was closed with running V-Loc suture. Pelvis was lavaged with copious amount of normal saline and hemostasis was found to be secure.
The 12 mm supraumbilical Surgiport was removed and the incision was closed in layers using an Endoclose. Fascia was closed with 2-0 Vicryl.
All the Surgiports were then removed under direct visualization. Indigo carmine was given intravenously. A cystoscopy was performed. Both ureteral orifices were identified. There was noted to be blue dye extravasating from both ureteral orifices. Foley was placed back into the bladder.
The incision was closed with interrupted 3-0 plain suture. All sponge, needle and instrument counts were found to be correct. The urine in the Foley bag was noted to be clear blue.
The patient tolerated the procedure well and was sent to the recovery room in excellent condition.
