DATE OF SURGERY: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Postmenopausal bleeding with complex atypical endometrial hyperplasia noted on pathology report from dilatation and curettage.
POSTOPERATIVE DIAGNOSIS:
Postmenopausal bleeding with complex atypical endometrial hyperplasia noted on pathology report from dilatation and curettage, pathology pending.
OPERATIONS PERFORMED:
1. Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO).
2. Exploratory laparotomy with extensive lysis of adhesions.
SURGEON: John Doe, MD
ANESTHESIA:
Epidural and general.
SPECIMENS REMOVED:
Uterus and cervix with bilateral tubes and ovaries. Thick adhesions of the large and small bowel were noted to the posterior fundal surface of the uterus.
ESTIMATED BLOOD LOSS:
350 mL.
COMPLICATIONS:
None.
CONDITION OF PATIENT:
Stable post surgery.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was taken to the operating room for total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO). The abdomen was prepped and draped in the usual manner for major abdominal surgery. An indwelling Foley catheter was inserted. The patient’s ileostomy site was covered with a lap sponge and then a Vi-Drape placed across the prepped abdomen to ensure its integrity intraoperatively from the surgical field.
Given the patient’s previous midline incision, it was decided to attempt to proceed with a Pfannenstiel incision hoping to avoid the ileostomy site with its possible adhesions. The procedure was started by creating a Pfannenstiel incision 1 to 2 fingerbreadths above the pubic symphysis using sharp dissection with a scalpel. The scalpel was then used to dissect sharply downward toward the anterior rectus fascia which was nicked with the scalpel. The Mayo scissors was used to extend the fascial incision bilaterally in a curvilinear fashion. The underlying rectus muscle was identified and separated by both blunt and sharp dissection with Metzenbaum scissors. The parietal peritoneum was identified, grasped with pickups with teeth x2, nicked with a scalpel and then the pelvis and abdominal cavity entered in the usual manner.
Given the patient’s previous surgery, some very thick vascular adhesions were noted of the large and small bowel to the posterior fundal surface of the uterus. A Balfour retractor was placed with the bladder blade to keep the bladder out of the operative field. The bowel was packed with 3 moist lap sponges to keep it out of the pelvis. Dr. Doe performed extensive dissection of the posterior fundal surface of the uterus to free the posterior cul-de-sac so that we could proceed safely with a hysterectomy.
The procedure was started by grasping each of the round ligaments, grasping them and dividing them and opening the anterior peritoneal leaflet and bringing it down across the lower uterine segment. The retroperitoneal space was then opened and each ureter identified on both sides to ensure that they were far out of the operative field intraoperatively. The infundibulopelvic ligaments were then identified and grasped with Heaney clamps x2. These were then transected and suture ligated with 0-Vicryl suture.
The gallbladder was carefully and tediously dissected down off the lower uterine segment, as it was thought to be fairly thickly adhered to the lower uterine segment. Heaney clamps were then used to come across the broad ligaments and the uterine arteries. These were then transected and suture ligated with 0-Vicryl suture. Heaney clamps were then placed serially down to the level of the uterosacral ligaments, which were then transected and suture ligated with 0-Vicryl suture.
The vagina was then entered sharply with a scalpel, then Jorgenson scissors was used to amputate the cervix and uterus with tubes and ovaries from the vaginal cuff. There were several small pieces of what was thought to be cervix that remained and these were then removed with Mayo scissors using sharp dissection and also to submit the specimens for pathology. The vaginal cuff was then grasped with long Kochers. Corner stitches of 0-Vicryl suture were then placed and the vaginal cuff closed with an 0-Vicryl suture in a running interlocking fashion.
The pelvis was then irrigated with copious amounts of warm normal saline. There were several areas of oozing noted on the vaginal cuff, and these were hemostatically secured using figure-of-eight stitches of 3-0 chromic and 2-0 Vicryl sutures. When excellent hemostasis had been achieved, the pelvis was irrigated one final time, all operative sites inspected and excellent hemostasis noted.
The muscles were then reapproximated using simple stitches of 0-Vicryl suture. The fascia was then closed with 0-Maxon in a running non-interlocking stitch in 2 segments. The skin was irrigated with warm normal saline. Electrocautery was used for hemostasis. The skin was finally reapproximated using a running subcuticular stitch of 3-0 undyed Vicryl suture. Tincture of benzoin and Steri-Strips were applied to the incision.
The patient returned to the recovery room postoperatively at the end of the total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) with all sponge and instrument counts found to be correct.
