PREOPERATIVE DIAGNOSES:
1. Ovarian cyst.
2. Uterine cancer.
3. Postmenopausal bleeding.
4. Pelvic pain.
5. Intermittent urinary
incontinence.
6. Prolapse.
POSTOPERATIVE
DIAGNOSES:
1. Ovarian cyst.
2. Uterine cancer.
3. Postmenopausal bleeding.
4. Pelvic pain.
5. Intermittent urinary
incontinence.
6. Prolapse.
OPERATION
PERFORMED:
1.
Extended hysterectomy with bilateral salpingo-oophorectomy, proximal
vaginectomy.
2.
Bilateral retroperitoneal lymphadenectomy.
3.
Pelvic washings.
4.
Left ureterolysis.
5.
Cystourethroscopy.
6.
Robotic da Vinci ‘S’ system laparoscopy.
SURGEON: Frank
Cirisano, MD
ASSISTANT:
Richard Monti, PA-C.
ANESTHESIA:
General.
COMPLICATIONS: None.
ESTIMATED
BLOOD LOSS: Less than 300 mL.
DISPOSITION: The patient was transferred to the recovery
room in stable condition.
JUSTIFICATION: The patient presented on 05/22/09 for the above procedures,
for the above diagnoses. The patient
understands the indications, rationale, potential complications and risks. She is aware that these risks include
infection, bleeding, injury to adjacent structures such as the bowel or bladder
as well as potential cardiac or pulmonary complications and risk of anesthesia. The patient is aware of the potential of
thromboembolic events including deep venous thrombosis, stroke, and pulmonary
embolus. She is aware that her risks may
be elevated given her prior medical history, diagnosis of malignancy, and
anticipated surgical procedures. All of
the patient's questions have been answered, apparently to her
satisfaction. The patient has elected to
proceed with surgery and is medically cleared.
PROCEDURE IN DETAIL: Following documentation of
informed consent for the above procedures, the patient was brought to the
operative suite where she was administered general anesthesia, prepped and
draped in the usual sterile fashion in the low lithotomy position in Allen
stirrups. A supraumbilical incision was
made with the 11 blade knife to accommodate the Veress needle. Its location was established by saline drop
test, infusion, and aspiration test. The
abdomen was insufflated with several liters of CO2 gas. The Veress needle was removed. The supraumbilical incision was dilated to
accommodate the 12 mm port, which was placed.
The laparoscope was introduced into the abdominal cavity. Initial examination of the abdomen and pelvis
was conducted. Findings were notable for
adhesions involving the right and left adnexa, right and left pelvic sidewalls,
uterine fundus, and rectosigmoid colon.
Accessory trocars were placed midway between the anterior superior iliac
crest and the umbilicus on both sides using 8 mm ports. A 12 mm port was placed two fingerbreadths
above the umbilicus and two fingerbreadths to the left on the lateral aspect of
the supraumbilical incision. All ports
were placed under direct visualization to avoid injury to underlying
structures. Abdominal wall
transillumination was utilized to avoid regional blood supply. A thorough and systematic exploration of the
abdomen and pelvis was again conducted and the bowels were gently packed into
the upper abdomen with Trendelenburg positioning aided by atraumatic grasping
forceps. The robotic da Vinci ‘S’ system
was docked to the patient. The round
ligaments were divided on both sides.
The pararectal and paravesical spaces were thoroughly developed with
identification of the ureters and major vessels in their pelvic course. Right ureterolysis was carried out to
mobilize the ureter from the medial leaf of the broad ligament from the level
of the pelvic rim to the level of uterine vessels. In the same manner on the left side, the
ureter was freed from the medial leaf of the broad ligament and reflected
laterally. The IPL ligaments are
isolated. Bipolar cautery was used to
secure exact hemostasis and the vessels are divided. A bladder flap was developed by blunt and
sharp dissection. The uterine vessels
were skeletonized, clamped, cauterized, and divided at the level of the uterine
isthmus. Pedicles are secured using
bipolar cautery in the same manner with parametrial tissues taken down to the
level of the proximal vaginal cuff, which is further mobilized and the proximal
vagina is released by take down of the paravaginal tissues on both sides.
The colpotomy incision is carried out circumferentially incising the
vaginal cuff utilizing the cervical _____ uterine manipulator as a guide. The specimens were delivered via the vaginal
vault and sent to Pathology. The vaginal
cuff was closed using a running suture of 0 Vicryl. The abdomen and pelvis were irrigated. Washings were also obtained prior to
initiation of surgery. Retroperitoneal lymphadenectomy
was carried out mobilizing nodal tissue from the length of the external iliac
artery and vein beginning caudad at the level of the circumflex iliac
vein. Dissection was carried out in a
lateral to medial direction working to the level of the aortic
bifurcation. The ureters were reflected
medially and held under direct visualization in the course of ongoing
dissection to a level two fingerbreadths above the aortic bifurcation. Care was taken to isolate or preserve vital
structures with exact hemostasis noted upon completion. The abdomen and pelvis were again generously
irrigated. Hemostasis noted at all
pedicles. All instruments removed from
the abdomen and pelvis, and the robotic da Vinci ‘S’ system was undocked. All trocar sites are closed using 0 Vicryl
suture to re-approximate the fascial margins and 4-0 Monocryl to re-approximate
skin margins. Dressings were
applied. The perineum was
approached. The Foley catheter was
removed. Cystourethroscopy was
performed. The findings were notable for
free spill of indigo carmine dye from both the right and left ureteral
orifices. The bladder mucosa and the
urethral mucosa were free of gross suture violation, free of evidence of any
injury or gross pathology. All
instruments were removed from the vagina and perineum, and the Foley catheter
was replaced in the bladder. The patient
was awakened from anesthesia, returned to the recovery room in stable
condition.
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