Robotic laparoscopy with bilateral salpingo-oophorectomy Extensive pelvic and abdominal enterolysis Cystourethroscopy

PREOPERATIVE DIAGNOSES:

1.  Ovarian cyst.

2.  Pelvic mass.

3.  Pelvic pain.

4.  Prior hysterectomy.

5.  Prior abdominal surgery, colectomy.

6.  Deep vein thrombosis.

7.  Urinary incontinence.

POSTOPERATIVE DIAGNOSES:

1.  Ovarian cyst.

2.  Pelvic mass.

3.  Pelvic pain.

4.  Prior hysterectomy.

5.  Prior abdominal surgery, colectomy.

6.  Deep vein thrombosis.

7.  Urinary incontinence.

8.  Benign ovarian cyst.

OPERATION PERFORMED:

1.  Robotic laparoscopy with bilateral salpingo-oophorectomy.

2.  Extensive pelvic and abdominal enterolysis.

3.  Cystourethroscopy.

SURGEON:                                                  Frank Cirisano, MD

ASSISTANT:                                                Richard Monti, PA-C

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 04/08/09 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 potential cardiac or pulmonary complications, and risk of anesthesia.  The patient is aware of the potential for thromboembolic events including previous deep vein thrombosis, potential for stroke, pulmonary embolus, and thromboembolic events.  The patient is aware that her risks are elevated given her prior medical history, previous management for deep vein thrombosis, and 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 and Allen stirrups.  A supraumbilical incision was made with the 11 blade knife to accommodate the Veress needle, which was placed.  Its location is 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 supraumbilical incision was dilated to accommodate the 12-mm port, which was placed.  The laparoscope was introduced into the abdominal cavity.  Initial examination of the abdomen and pelvis was conducted.  Accessory trocars are placed midway between the anterior superior iliac crest and the umbilicus on both sides using 8-mm ports.  A 12-mm port was placed two fingerbreadths above the symphysis pubis, left of midline two fingerbreadths.  All ports are placed under direct visualization to avoid injury to underlying structures.  Abdominal wall transillumination was utilized to avoid regional blood supply.  Washings were obtained.  A thorough and systematic exploration of the abdomen and pelvis was conducted.  Findings were notable for severe pelvic and abdominal adhesions, _____ small bowel loops within the abdomen, within the pelvis.  The robotic da Vinci S system was docked to the patient.  The console was approached.

Extensive pelvic and abdominal enterolysis was carried out.  Endoshears were utilized to meticulously dissect adhesions involving large and small bowel loops within the upper abdomen and within the pelvis.  The omentum was mobilized from _____ to the right pelvic sidewall with layering over the adnexal structures, right and left within the pelvis.  A 6-cm cystic mass was noted within the pelvis, arising from the left adnexa with adherence to the right adnexa in the midline.  Approximately, 50 minutes of an operative time was utilized to complete the operative dissection, mobilizing large and small bowel loops, and gently packing the loops into the upper abdomen with the aid of Trendelenburg positioning and atraumatic grasping forceps.  Following extensive enterolysis, the adnexal structures were identified and isolated.

The round ligament remnants were isolated on both sides, divided, and the pararectal and paravesical spaces are clearly developed with identification of the ureters and major vessels and their pelvic course.  The infundibulopelvic ligaments were further isolated, and a window was developed to separate the IP ligament from vital structures.  The ureters were reflected laterally.  The IP ligament was divided on both sides with the aid of the Endo GIA stapler with hemostasis noted bilaterally.  The remaining attachments of the right and left adnexa to the right and left pelvic sidewall were taken down by blunt and sharp dissection, and both the right and left adnexa were delivered via the 12-mm port site contained within an endopouch.  The areas of the pelvis were irrigated with hemostasis noted at all pedicles.  All instruments were removed from the abdomen and pelvis.  The robotic da Vinci S system was undocked, and cystourethroscopy was performed.  Findings were notable for free spill of indigo carmine dye from both the right and left ureteral orifice.  The bladder mucosa and the urethral mucosa were free of gross suture violation, free of evidence of any injury or gross pathology.  All instruments were removed from the bladder.  The Foley catheter was replaced in the bladder.  Small abdominal incisions were closed using 0 Vicryl to reapproximate the fascial margins and 4-0 Monocryl to reapproximate skin margins.  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.