Operative laparoscopic ablation of endometriosis

PREOPERATIVE DIAGNOSIS:                Pelvic pain, suspicion of endometriosis.

POSTOPERATIVE DIAGNOSIS:             Pelvic pain with confirmed endometriosis.

PROCEDURE PERFORMED:                  Operative laparoscopic ablation of endometriosis.

ANESTHESIA:                                             General.

EBL:                                                               None.

COMPLICATIONS:                                                 None.

SPECIMEN SENT:                                                 None.

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

PROCEDURE IN DETAIL:                        The patient was taken to the Operating Room where she was identified as herself, placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the vagina, and Deaver was placed anteriorly.  The anterior lip of the cervix was grasped with a single-tooth tenaculum.  Cervix was dilated to accommodate a HUMI uterine manipulator, which was introduced into the uterine cavity, and the intrauterine balloon was insufflated.  The Deaver and speculum were removed from the patient’s vagina, and attention was turned to the patient’s abdomen.  A 5-mm incision was made in the umbilical fold, and the Veress needle introduced into the intraabdominal cavity.  Intraabdominal placement was confirmed by appropriate pressure readings.  The abdomen was insufflated with CO2 gas.  The Veress needle was removed, and a 5-mm trocar was introduced.  The patient was placed in steep Trendelenburg positioning with the bowel displaced superiorly, and a second incision was made in the left lower quadrant to accommodate a 5-mm trocar under direct visualization.

Findings that were appreciated were a normal-appearing uterus with normal fallopian tubes and ovaries that bilaterally spilled indigo carmine dye during the chromotubation without any compromise.  Of note, was significant evidence of retrograde menstrual flow that was actively occurring at the time of laparoscopy secondary to the patient’s menstrual cycle being in progress.  Endometriosis implants were noted specifically most concentrated along the right uterosacral ligament with the largest percentage of these lesions identified there but also disbursed amongst the posterior pelvic cul-de-sac.  No other specific abnormalities.  No fibroids.  No other pathology or adhesions or compromise of the fallopian tubes were appreciated.  At this time, utilizing the Carpenter bipolar cautery, the lesions along the right uterosacral ligament were cauterized judiciously, and then the abdomen was copiously irrigated and cleared of all clots and debris.  All instruments were subsequently removed from the patient’s abdomen and vagina.  Again of note, chromotubation utilizing indigo carmine dye instilled through the HUMI uterine manipulator was done with bilateral spillage from both fallopian tubes without any compromise appreciated.  The two skin incisions were closed with 4-0 Monocryl for excellent hemostasis and reapproximation.  One-twelfth CO2 gas was expelled from the patient’s abdomen.  Sponge, needle, and instrument counts were correct x2.  The patient was taken to the recovery room with the Foley discontinued in the Operating Room and the Foley bag having shown clear yellow urine.  The patient’s instructions had been discussed with her prior to surgery with plans for discharge home today, over-the-counter pain medication, and followup in our office in approximately a week.

FINDINGS:  The findings showed a normal-sized and normal-appearing uterus, normal fallopian tubes and ovaries bilaterally with active retrograde menstrual bleeding into the pelvic cavity and endometriosis implants specifically concentrated in the posterior pelvic cul-de-sac and specifically along the right uterosacral were identified.