Repeat low-flap cesarean section and tubal ligation

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