Laparoscopic myomectomy, lysis of adhesions, and chromotubation

PREOPERATIVE DIAGNOSIS:                Fibroids.

POSTOPERATIVE DIAGNOSES:           Fibroids with lysis of adhesions and chromotubation.

OPERATION PERFORMED:                    Laparoscopic myomectomy, lysis of adhesions, and chromotubation.

SPECIMENS REMOVED:                         Morcellated segments of fibroids.

ANESTHESIA:                                             General.

EBL:                                                               Minimal.

URINE OUTPUT:                                        Clear yellow urine throughout the course of the procedure.

FINDINGS:                                                    Operative findings revealed a 5 to 6-cm pedunculated right cornual fibroid that was adhesed to the right fallopian tube and compressing the right fallopian tube with otherwise normal-appearing right fallopian tube and ovary.  On the left, there was a 3-cm pedunculated left cornual fibroid with otherwise completely normal left fallopian tube and ovary.  The uterus itself appeared normal configuration with maybe a 1-cm intramural fibroid noted in the posterior wall of the uterus.  Otherwise, normal liver edge, normal appendix, and normal gallbladder.

PROCEDURE IN DETAIL:                        The patient was taken to the operating room where she was identified as herself, placed in the dorsal lithotomy position after general anesthesia was administered without difficulty.  She was prepped and draped in the usual sterile fashion and a weighted speculum was placed in the vagina with the anterior lip of the cervix grasped with a single-toothed tenaculum.  The cervix was dilated to accommodate a HUMI manipulator.  The HUMI manipulator was introduced into the uterine cavity and insufflated with all instruments removed from the patient’s vagina.  Attention was turned to the patient’s abdomen where a 5-mm incision was made in the umbilical fold, and a Veress needle introduced into the abdominal cavity where intraabdominal placement was confirmed by appropriate pressure readings.  The abdomen was insufflated with CO2 gas and the Veress needle was removed with the 5-mm trocar introduced and appropriate intraabdominal placement confirmed by the 0-degree laparoscope.  The two further incisions were made in the left lower quadrant and right lower quadrant to accommodate 10-mm trocars under direct visualization lateral to the inferior epigastric vessels.  At this time, again the findings noted above prompted us to proceed with first excising the adhesions of the right subserosal 5 to 6-cm fibroid that were compressing the right fallopian tube.  These were judiciously dissected free and then the pedunculated stalk was cauterized, and transected with the Gyrus instrument and the entire fibroid was removed with complete hemostasis of the pedunculated stalk.  The left subserosal pedunculated cornual 2 to 3-cm fibroid was similarly excised, cauterized at its stalk, and noted to be hemostatic.  At this time, the Gynecare morcellator was introduced to the left lower quadrant port site and both fibroids were morcellated with all specimens removed to the left lower quadrant.  The abdomen was copiously irrigated, cleared of all clots and debris, and the pedunculated stalks of attachment from the two fibroids that have been removed were noted to be hemostatic.  Methylene blue chromotubation was performed with bilateral spill of the methylene blue to the pelvic cavity showing that there was complete patency of both fallopian tubes.  At this time, again, the abdomen was copiously irrigated, cleared of all clots and debris.  All instruments were removed from the patient’s abdomen and vagina, and CO2 gas was expelled.  The two 10-mm fascial defects in the right lower quadrants and left lower quadrants respectively were closed with interrupted 0-Vicryl suture, and the skin was closed with 4-0 Monocryl in subcuticular fashion for excellent hemostasis and reapproximation.  Sponge, needle, and instrument counts were correct x2.  The patient was taken to the recovery room in stable and awake condition, with discharge to home plan for the same day.  Discharge instructions were reviewed with the patient prior to surgery and with the patient’s husband in the waiting room at the time that I discussed the findings.  The patient will follow up in my office on 12/23/08.