Total abdominal hysterectomy Extensive pelvic enterolysis Bilateral ureterolysis Pelvic washing Bilateral ovarian transposition and preservation

PREOPERATIVE DIAGNOSES:

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.