Extended hysterectomy with bilateral salpingo-oophorectomy, proximal vaginectomy Bilateral retroperitoneal lymphadenectomy Pelvic washings Left ureterolysis Cystourethroscopy Robotic da Vinci ‘S’ system laparoscopy

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.