PREOPERATIVE
DIAGNOSES: Previous cesarean section and labor and undesired fertility, A2 diabetes,
two-vessel cord.
POSTOPERATIVE
DIAGNOSES: Previous C-section and labor and undesired fertility, A2 diabetes,
two-vessel cord.
PROCEDURE: Repeat
low-flap cesarean section and
tubal ligation.
FINDINGS: A
live male infant with Apgars of 9 and 9, the baby weighed 7 pounds 2
ounces. There were normal tubes and
ovaries bilaterally. There was noted to
be scar from the bladder to the anterior abdominal wall and the anterior
uterine wall.
COMPLICATIONS:
None.
ANESTHESIA:
Spinal.
ESTIMATED
BLOOD LOSS: 800 mL.
PROCEDURE IN DETAIL: The patient was brought to the operating
room where anesthesia was obtained without difficulty. She was prepped and draped in normal sterile
fashion in dorsal supine position with a leftward tilt. A Pfannenstiel skin incision was made with
the scalpel and carried through the underlying layer of fascia with blunt and
sharp dissection. The fascia was nicked
on either side of the midline, and the incision was extended laterally with the
curved Mayo scissors. Inferior aspect of
the fascial incision was grasped with the Kocher clamps, elevated off the
rectus muscles. Rectus muscles were
dissected off bluntly and sharply.
Attention was turned to the superior aspect, which in a similar fascia
was dissected off bluntly and sharply.
The peritoneum was entered sharply, and the incision was extended
laterally with blunt dissection. The
bladder blade was inserted, and the vesicouterine peritoneum was incised in a
transverse fashion. The Bovie cautery
was used to help lower the adhered bladder from the anterior abdominal wall and
the anterior uterine wall. The bladder
blade was reinserted. The scalpel was
used to make the uterine incision, and the incision was extended laterally with
blunt dissection. A live male infant was
delivered atraumatically. The nose and
mouth were suctioned on the field. The
cord was clamped and cut, and the infant was handed to pediatricians who signed
Apgars of 9 and 9. The baby weighed 7
pounds 2 ounces. Placenta was delivered
spontaneously. Uterus was cleared of all
clots and debris, and the incision was closed with 0 chromic in a continuous
locking fashion. The repair of the
uterus was done cautiously, as the bladder was pulled high on the lower uterine
segment. There was noted to be a small
amount of bleeding in the midline and a figure-of-eight suture was placed
there. The Bovie cautery was used for
hemostasis along the peritoneal edge where the bladder had been dissected off
the anterior abdominal wall and the anterior uterine wall. At this point, a lap was placed over the
incision, and attention was turned to the tube.
The left tube was grasped with the Babcock clamp, elevated, and tied
with 0 plain tie x2. In the midportion,
the Metzenbaum scissors were used to transect the tube and this was sent to
Pathology. The tube itself was noted to
be hemostatic. Attention was turned to
the other tube where midportion of the tube was grasped with Babcock clamp; two
3-0 plain ties were placed. The tube was
transected with the Metzenbaum scissors, and the tube itself was noted to be
hemostatic. The ovaries were normal
bilaterally on both sides. Attention was
returned to the incision where there was noted to be again some bleeding along
the peritoneal edge where the bladder had been dissected. The Bovie cautery was used as well as a
figure-of-eight suture for hemostasis.
When all the areas were noted to be hemostatic, attention was then turned
to the fascia, which was closed with 1 Vicryl in a continuous fashion. Subcutaneous tissue was irrigated, Bovie
cautery was used for hemostasis, and the skin was closed with staples. Sponge, lap, and needle counts were correct
x2
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