Laparoscopic right ovarian paratubal cystectomy Omentectomy, resection of abdominal hematoma

PREOPERATIVE DIAGNOSES:

1.  Ovarian cyst.

2.  Pelvic mass.

3.  Pelvic pain.

4.  Adnexal torsion.

5.  Pelvic hematoma.

POSTOPERATIVE DIAGNOSES:

1.  Ovarian cyst.

2.  Pelvic mass.

3.  Pelvic pain.

4.  Adnexal torsion.

5.  Pelvic hematoma.

6.  Right paratubal cyst, torsion.

7.  Omental hematoma.

OPERATIONS PERFORMED:

1.  Laparoscopic right ovarian, paratubal cystectomy.

2.  Omentectomy, resection of abdominal hematoma.

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 presents on 04/10/09 for the above procedures and 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 potential cardiac or pulmonary complications, and risk of anesthesia.  The patient is aware of the potential for thromboembolic events including deep vein thrombosis, stroke, and pulmonary embolus.  The patient is aware of the potential for alteration in pelvic anatomy including potential future limitations in pregnancy carriage, and fertility.  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 and Allen stirrups.  An infraumbilical incision was made with the 11 blade knife to accommodate the Veress needle, which was placed.  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 umbilical incision was dilated to accommodate the 11 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 a right paratubal, ovarian cyst, with torsion noted, about the omentum with hematoma within the omentum spanning 4-5 cm.  Accessory trocars were placed midway between the anterior superior iliac crest and the umbilicus on the left side using a 5 mm port, with a 12 mm port placed two fingerbreadths above the symphysis pubis in the midline.  All ports were placed under direct visualization to avoid injury to underlying structures.  Abdominal wall transillumination was utilized to avoid regional blood supply.  Pelvic washings were obtained.  A thorough and systematic exploration of the abdomen and pelvis was conducted.  The above findings were again noted and confirmed.  The omentum was localized into the pelvis.  Omentectomy was carried out, resecting the omentum proximal to the area of hematoma, and adherent to the paratubal and paraovarian cyst.  Exact hemostasis was noted along the resection margin which was cauterized with bipolar cautery and Endoshears.  The mass and adnexa were mobilized in the lateral to medial direction.  The mass was resected from the region of the right pelvic sidewall, isolated and resected from mesovarium, and fallopian tube mesentery.  The mass was delivered to the abdomen, contained within an Endopouch, via the 12 mm port site.  The abdomen and pelvis were irrigated.  Good hemostasis was noted at all pedicles.  All instruments were removed from the abdomen and pelvis.  All accessory trocars were removed followed by the laparoscope and the umbilical trocar.  Air was allowed to escape from the abdominal cavity.  0 Vicryl suture was used to reapproximate the fascial margins followed by 4-0 Monocryl used to reapproximate skin margins.  Dressings were applied.  All sponge and needle counts were correct x3 at the end of the case.  The patient tolerated these procedures well, and was transferred to the recovery room in stable condition.