Robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy

PREOPERATIVE DIAGNOSIS:                Pelvic pain, dysfunction and uterine bleeding.

POSTOPERATIVE DIAGNOSIS:                         Pelvic pain, dysfunction and uterine bleeding.

PROCEDURE:                                             Robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy.

ANESTHESIA:                                             General.

FINDINGS:                                                    Normal size uterus with normal tubes and ovaries bilaterally, normal upper abdomen.

ESTIMATED BLOOD LOSS:                    50 mL.

DESCRIPTION OF PROCEDURE:         Under adequate general anesthesia, the patient was prepped and draped in dorsal lithotomy position in the standard fashion.  Examination under anesthesia revealed a normal size uterus without palpable adnexal masses.  A weighed speculum was placed in vagina.  The cervix was grasped with a single-toothed tenaculum at the 12’o clock position and the cervix was tagged at the 6 and 12’o clock positions with a 0 Vicryl sutures.  The cervix was dilated with Hanks dilators and a VCare apparatus was passed into the uterus for uterine manipulation during the planned operative procedure.  Attention was then turned toward the abdomen, where a supraumbilical incision was made with a knife and Veress needle was applied into the peritoneal cavity.  Peritoneal positioning was confirmed.  The CO2 gas was insufflated for creation of an adequate intraperitoneal bubble.  The #12 trocar followed by the laparoscope was then passed into the peritoneal cavity.  Under direct visualization, assistant ports and arms 1, 2 and 3 of the robot were passed under direct visualization.  Robot arms were #8 trocars, the assistant port was a #10 trocar.  These were passed in the right and left lower quadrants respectively under direct visualization.  The uterus was then elevated and the round ligaments were identified, and grasped with a bipolar forceps, desiccated and incised with the hot shears.  The ovaries were identified.  The adhesions of the left ovary to the pelvic sidewall, these were lysed with both sharp and blunt dissection grossly consistent with a small focus of endometriotic scarring.  With adequate mobilization of the left ovary, the infundibulopelvic ligament was identified.  The broad ligament was entered over the medial border of the psoas muscle.  The defect was created in the posterior broad ligament over the course of the uterus.  Under direct visualization, the infundibulopelvic ligament was grasped with a bipolar forceps, desiccated and incised with the hot shears.  The procedure was repeated on the right hand side.  The right ovary was freely mobilized.  The broad ligament entered and a defect was created in the posterior broad ligament.  The infundibulopelvic ligament was skeletonized, isolated and grasped with the bipolar forceps under direct visualization with the ureter visualized.  The pedicle was then desiccated using the bipolar forceps and incised using the hot shears.  The uterine vessels were then skeletonized.  The vesicouterine peritoneum was then identified and the bladder mobilized and _____ portion of the uterine cervix with adequate mobilization of the cervix, the VCare was visualized protruding through the underlying vagina.  The uterine vessels were then grasped with the bipolar forceps, desiccated and incised and carried down to the VCare as the cardinal ligaments were serially transected with Bovie cautery and unipolar hot shears.  Upon adequate mobilization of the vascular pedicle, the vaginal cuff was entered anteriorly.  The groove of the VCare was identified.  The cervix was circumscribed with careful attention paid to staying within the groove of the VCare.  The specimen was removed from its attachment and taken out through the vagina.  The vaginal cuff was then reapproximated using interrupted figure-of-eight sutures of #1 Vicryl using laparoscopic suturing techniques.  The abdomen was then irrigated with normal saline irrigation, where vascular pedicles down for hemostasis, which was assured.  Closure of the ureter was examined and found to be freely peristaltic.  The fascial ports of the #10 and #11, assistant port and the umbilical port were then closed with use of the fascial closure device with 0 Vicryl suture.  The skin incisions were then closed using a running subcuticular suture of 4-0 Monocryl and Steri-Strips were applied to the skin.  The patient tolerated all the procedures well.  Estimated blood loss was approximately 50 mL.  Instrument and sponge counts were correct.  The patient was taken to the recovery room and awakened in good and stable condition.