1.
Pelvic mass.
2.
Pelvic pain.
3.
Uterus myoma.
4.
Malignancy not excluded.
POSTOPERATIVE
DIAGNOSES:
1.
Pelvic mass.
2.
Pelvic pain.
3.
Uterus myoma.
4.
Malignancy not excluded.
OPERATION
PERFORMED:
1. Total
abdominal hysterectomy.
2.
Extensive pelvic
enterolysis.
3.
Bilateral ureterolysis.
4.
Pelvic washing.
5.
Bilateral ovarian transposition and preservation.
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 05/22/09
for the above procedures, for the above diagnoses. The patient understands the indications,
rationale, potential 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 of
thromboembolic events including deep venous thrombosis, stroke, and pulmonary
embolus. She is aware that her risks may
be elevated given her prior medical history, possible diagnosis of malignancy,
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 in Allen stirrups. A
low-transverse skin incision was developed two fingerbreadths above the
symphysis pubis. A Pfannenstiel incision
was developed. The abdomen was
entered. Abdominal and pelvic washings
were obtained. A thorough and systematic
exploration of the abdomen and pelvis was conducted. The above findings were noted. The bowel loops were packed into the upper
abdomen with the aid of the Bookwalter retractor. The round ligaments were divided on both
sides. The pararectal and paravesical
spaces were clearly developed with identification of the ureters and major
vessels and their pelvic course.
Bilateral ureterolysis was carried out from the level of the pelvic rim
to the level of the uterine vessel. The utero-ovarian
ligament and proximal fallopian tubes were isolated to pedicles on both
sides. The structures are isolated,
clamped, divided, and doubly-ligated on both sides using 2-0 silk ligature
gut. A bladder flap was developed by
blunt and sharp dissection. The uterine
vessels were skeletonized, clamped, and divided at the level of the uterine
isthmus. Pedicles were secured using
suture ligatures of 0 Vicryl used throughout this case unless otherwise
specified. The parametrial tissues were
taken down in the same manner to the level of the proximal vaginal cuff. The proximal vaginal cuff was further
mobilized, clamped, divided, and the specimens were removed from the operative
field including the uterus and cervix.
Angle sutures of 0-Vicryl were placed at both lateral aspects of the
vaginal cuff apex. The medial margins
were closed using interrupted figure-of-eight sutures with hemostasis noted.
The abdomen was
then closed using #1 loop PDS to reapproximate the fascial margins followed by
skin closure with 4-0 Monocryl.
Dressings were applied. 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.
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