Robotic-assisted total laparoscopic hysterectomy

PREOPERATIVE DIAGNOSIS:  Symptomatic fibroid uterus.

POSTOPERATIVE DIAGNOSIS:  Symptomatic fibroid uterus.

PROCEDURE PERFORMED:  Robotic-assisted total laparoscopic hysterectomy.

ANESTHESIA:  General.

EBL:  Minimal.

URINE OUTPUT:  Clear yellow urine throughout the course of the procedure with blue-tinged urine at the end of the procedure secondary to administration of indigo carmine dye.

SPECIMENS SENT:  Uterus and cervix.

COMPLICATIONS:  None.

PROCEDURE IN DETAIL:  The patient was taken to the operating room where she was identified as herself, placed in the dorsal lithotomy position with general anesthesia administered without difficulty.  She was prepped and draped in the usual sterile fashion and a weighted speculum was placed in the vagina and a Deaver was placed anteriorly.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and the cervix was dilated to accommodate the VCare uterine manipulator, which was introduced into the uterine cavity with the intrauterine balloon insufflated and the appropriately sized colpotomy cup placed around the cervix snugly.  The Deaver and tenaculum and speculum were removed from the patient’s vagina, and attention was turned to the patient’s abdomen.  A 12-mm incision was made approximately two fingerbreadths above the umbilicus, and a Veress needle was 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 12-mm trocar was introduced with a 0-degree laparoscope confirming intraabdominal placement.  Findings were that of slightly enlarged multifibroid uterus about 9 to 10 weeks in size, boggy in appearance, suspicious for adenomyosis, it was otherwise completely normal fallopian tubes and ovaries bilaterally.  The patient was placed in steep Trendelenburg positioning and the bowel was displaced superiorly with the robotic trocar arms placed in the left lower quadrant and right lower quadrants respectively under direct visualization accommodating the 8-mm robotic trocar site.  A final fourth incision was made in the right upper quadrant to accommodate a 12-mm surgical assistant port site.  The da Vinci robot was subsequently docked without any complications, and I removed myself _____.  After the surgical console, the surgery began with my identification of the utero-ovarian ligaments on either side.  These were cauterized and transected with the bipolar cautery and then the EndoShears.  This was followed by the round ligament, which was cauterized and transected in a similar fashion.  The anterior leaf of the broad ligament was entered and the bladder flap dissected off of the lower uterine segment and cervix without complications.  The uterine arteries bilaterally were skeletonized, cauterized, and transected.  At this time, the uterus was blanched effectively demonstrating that the blood supply to the uterus had been terminated.  The colpotomy cup was made with the monopolar spatula and carried around the entire cervicovaginal junction until the cervix and uterus were released from its moorings to the vagina.  The cervix and uterus were pulled into the vagina where it provided pneumo-occlusion while I proceeded to close the vaginal cuff with a running #0 Vicryl suture for excellent hemostasis and reapproximation.

The abdomen was copiously irrigated, cleared of all clots and debris, and the pedicles were examined and noted to be hemostatic.  The ureters were examined bilaterally and noted to be peristalsing normally with again indigo carmine dye noted to be draining into the Foley catheter with no extravasation into the pelvic cavity.  All the instruments were subsequently removed from the patient’s abdomen and vagina, and the two 12-mm fascial defects in the right upper quadrant and the above the umbilicus were closed with #0 Vicryl stitch, and the four skin incisions were closed with #4-0 Monocryl for excellent hemostasis and reapproximation.  The patient was taken to recovery room in stable and awake condition with plans for discharge home tomorrow morning.  Surgery was discussed in depth with the patient’s family with all questions answered.