Repeat low-flap cesarean section and lysis of adhesions

PREOPERATIVE DIAGNOSIS:  Previous cesarean section, desires repeat.

POSTOPERATIVE DIAGNOSIS:  Previous cesarean section, desires repeat with adhesions.

PROCEDURE:  Repeat low-flap cesarean section and lysis of adhesions.

FINDINGS:  A live female infant with Apgars of 9 and 9.  The baby weighed 8 pounds even.  There were normal tubes and ovaries bilaterally, and there was a thick scar of the bladder and uterus to the anterior abdominal wall.

COMPLICATIONS:  None.

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 a normal sterile fashion in dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with blunt and sharp dissection.  The fascia was nicked on either side of the midline.  The incision was extended laterally with the curved Mayo scissors.  Inferior aspect of the fascial incision was grasped with the Kocher clamps and elevated off the rectus muscles.  Rectus muscles were dissected off bluntly and sharply.  Attention was turned to the superior aspect, which in a similar fashion was dissected off bluntly and sharply.  The rectus muscles were separated in the midline.  The peritoneum was entered sharply, and the incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder was noted to be adherent to the uterus and to the anterior fascial wall.  Wall of the bladder was pushed inferiorly.  The Metzenbaum scissors were used carefully to facilitate dissection of the bladder off the uterus.  A minimal bladder flap was able to be created because of this, and this was pushed inferiorly.  The uterus was then incised with the scalpel, and the incision was extended laterally with the bandage scissors.  A live female 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 8 pounds.  Placenta was delivered spontaneously.  The uterus was cleared of all clots and debris, and the incision was closed with 0 chromic in a continuous locking fashion.  The incision was noted to be hemostatic.  The Bovie cautery was used for hemostasis along the bladder and uterine edge.  The gutters were cleared of all clots and debris.  The tubes and ovaries were noted to be normal bilaterally.  The uterine incision was reinspected and noted to be hemostatic.  The fascia was then 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, and the patient was brought to the recovery in stable condition.