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.

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.

Dilation and curettage, hysteroscopy, and diagnostic laparoscopy

PREOPERATIVE DIAGNOSES:              Dysfunctional uterine bleeding and fibroid uterus.

POSTOPERATIVE DIAGNOSES:           Dysfunctional uterine bleeding and fibroid uterus.

OPERATION PERFORMED:                    Dilation and curettage, hysteroscopy, and diagnostic laparoscopy.

ANESTHESIA:                                             General.

EBL:                                                               None.

SPECIMEN SENT:                                      Endometrial curettings.

COMPLICATIONS:                                     None.

OPERATIVE FINDINGS:                           Hysteroscopic findings revealed a bilaterally normal tubal ostia, which were visualized without difficulty with what appeared to be a lush endometrial lining and some evidence of potential synechiae in the uterus, but the uterus was otherwise completely uniform in its cavity, and no evidence of polyps or impinging fibroids in the uterus itself.  Laparoscopically, the uterus appeared to be normal size with potential of a slight irregularity on the anterior surface consistent with possible intramural fibroids, but otherwise normal appearing fallopian tubes and ovaries bilaterally with no other pelvic pathology appreciated.

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 after general anesthesia was administered without difficulty.  A weighted speculum was placed in the vagina and the Deaver was placed anteriorly.  The anterior lip of the cervix was grasped with a single-tooth tenaculum, and the cervix was dilated to accommodate a 30-degree hysteroscope.  The 30-degree hysteroscope was introduced into the uterine cavity with the findings noted above, specifically normal tubal ostia visualized bilaterally, some evidence of possible synechiae in the uterus, but no other pelvic pathology appreciated with a lush endometrial lining and no polyps or fibroids in the uterine cavity.  The hysteroscope was removed, and the uterus was curetted until sufficiently gritty texture was noted throughout.  Once this was done, all instruments were removed from the patient’s vagina, and attention was turned to the patient’s abdomen.  A 5-mm incision was made above the umbilical fold, and the Veress needle was introduced with intraabdominal placement confirmed by appropriate pressure readings.  The abdomen was insufflated with CO2 gas.  The Veress needle was removed, and attention was turned to introducing a 5-mm trocar.  The 5-mm laparoscope introduced with the above finding.  Once the pelvis was visualized to our satisfaction with again no specific pathology noted inside the pelvis, all instruments were removed from the patient’s abdomen and vagina.  Sponge, needle, and instrument counts were correct x2.  The patient was taken to recovery room in stable and awake condition.  The findings were discussed in depth with the patient’s partner in the waiting room with the patient to be discharged home on the same day of surgery with followup in our office in approximately a week.

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.