Extended total abdominal hysterectomy with bilateral salpingo-oophorectomy, retroperitoneal lymphadenectomy, proximal vaginectomy Extensive pelvic and abdominal enterolysis Bilateral ureterolysis Pelvic drain placement Cystourethroscopy

PREOPERATIVE DIAGNOSES:

1.  Postmenopausal bleeding.

2.  Endometrial hyperplasia.

3.  Suspected uterine malignancy.

4.  Urinary incontinence.

POSTOPERATIVE DIAGNOSES:

1.  Postmenopausal bleeding.

2.  Endometrial hyperplasia.

3.  Suspected uterine malignancy.

4.  Urinary incontinence.

OPERATION PERFORMED:

1.  Extended total abdominal hysterectomy with bilateral salpingo-oophorectomy, retroperitoneal lymphadenectomy, proximal vaginectomy.

2.  Extensive pelvic and abdominal enterolysis.

3.  Bilateral ureterolysis.

4.  Pelvic drain placement.

5.  Cystourethroscopy.

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 05/08/09 for the above procedures, for the above diagnoses.  The patient understands the indications, rationale, presumptive 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 the _____ cardiac or pulmonary complications and risk of anesthesia.  The patient is aware of the _____ of a thromboembolic event including deep vein thrombosis, stroke, and pulmonary embolus.  She is aware that her risks may be elevated given her prior medical history, possible diagnosis, and malignancy, 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 low-transverse skin incision was made two fingerbreadths above the symphysis pubis.  A Pfannenstiel incision was developed.  The abdomen is entered.  Abdominal and pelvic washings are obtained.  A thorough and systematic exploration of the abdomen and pelvis was conducted.  Adhesions were noted involving the right and left adnexa, right and left pelvic sidewall.  The uterus was densely adherent to the anterior abdominal wall, and bladder dome.  The bowel loops are packed into the upper abdomen following extensive pelvic and abdominal enterolysis.  Adhesiolysis carried without within pelvis freeing the bowel loops from adhesions and from the adnexa, which allowed gentle packing of the bowel loops into the upper abdomen with the aid of the Bookwalter retractor.  The round ligaments were divided on both sides.  The pararectal and paravesical spaces are clearly developed with identification of the ureters and major vessels and their pelvic course bilaterally.  Ureters are freed from the medial leaf of the broad ligament and reflected laterally.  Bilateral ureterolysis was carried out from the level of the pelvic rim to the level of the uterine vessel.  A bladder flap was developed by blunt and sharp dissection.  The uterine vessels are skeletonized, clamped and divided at the level of the uterine isthmus.  Pedicles are secured using suture ligatures of 0 Vicryl used throughout this case unless otherwise certified.  The parametrial tissues are taken down in the same manner to the level of the proximal vaginal cuff.  The proximal vaginal cuff was further mobilized, clamped, divided, and the specimens are removed from the operative field using the uterus, cervix, both ovaries and tubes, proximal vagina.  Angle sutures of 0-Vicryl are placed at both lateral aspects of the vaginal cuff apex.  The medial margins are closed using interrupted figure-of-eight sutures of 0-Vicryl as well.  The abdomen and pelvis were irrigated.  Retroperitoneal lymphadenectomy was carried out.  Nodal tissue was excised on the right side with lymphadenopathy appreciated, 1 to 2 nodes.  Excision was carried out in the lateral to medial direction taking care to isolate and preserve the vital structures including the obturator, neurovascular bundle, external iliac artery and vein.  The ureters were reflected medially where it is held under direct visualization to avoid injury in the course of dissection.  The area was irrigated upon completion, notable for hemostasis.  The abdomen was then closed using #1 loop PDS suture to reapproximate the fascial margins over pelvic drain.  Skin margins are closed with staples.  Dressings were applied.  Cystourethroscopy was performed.  Findings are notable for free spill of indigo carmine dye from both the right and left ureteral orifice.  The bladder mucosa and ureteral mucosa are free of gross suture violation, free of evidence of any injury or gross pathology.  All instruments were removed from the vagina and perineum.  The Foley catheter is replaced in the bladder.  The patient is awakened from the anesthesia and returned to the recovery room in stable condition with all sponge and needle counts correct x3 at the end of the case.