Date: _______________
Surgeon: _______________
Assistant(s): _______________
Anesthesia: general
Anesthesiologist: Dr. _______________
PreOp Dx: Acute Pelvic Pain, possible hemorrhagic cyst
PostOp Dx: Right Ischemic Hematosalpinx
Operation: Diagnostic Laparoscopy with right salpingectomy
Operative Findings:

EBL: less than 100 cc
Specimens: right fallopian tube sent to pathology
Complications: none
Disposition:

Clinical Note: Ms. _______________ is a 25 year old female who presented with acute pelvic pain...

Procedure:
Under GA in the dorsal lithotomy position, the patient was prepped and drapped in the usual sterile fashion. A weighted speculum was placed in the vagina and with the help of a right angle retractor the cervix was visualized and grasped anteriorly with a single tooth tenaculum. The cervical os was dialated up to a #6 Hegar dilator that was left in place allowing mobilization of the uterus.

0.5% bupivicaine solution was infiltrated in the subumbilical area. A 10 mm subumbilical incision was made through the skin with a #11 blade and the Veress needle was inserted uneventfully in the peritoneal cavity. The peritoneal cavity was insufflated with CO2 gas to a maximum pressure of 20 mmHg. The Veress needle was then removed and a 10 mm trocar was introduced without difficulty through this site into the peritoneal cavity. The laparoscope was introduced and appropriate entry was confirmed. The abdominal cavity was examined to reveal a small amount of bloody fluid in the pelvix, a large ischemic, cystic mass extending into the posterior CDS, and no significant signs of adhesions or acute imflammation. There was also no signs of acute bleeding below to suggest injury from the veress needle.



Following this, three more 5 mm ports were placed. One in the left lower quadrant, one in the right lower quadrant, and the last approxiamtely a hand-length above the right, in the right upper quadrant. Each was inserted by first visually identifying a safe place on the abdominal wall with the laparoscopy, infiltrating the area with the bupivicaine solution under direct visualization, cutting the skin with the scalple, and then inserting a 5mm trocar under direct visuaization, taking care to not enter near any vessels or injury any peritoneal contents. The upper abdomen was visualized and a normal liver, gallbladder and diaphragm were seen. The appendix was also visualized and normal and at this point general surgery felt they could safely sign off from the case.

With graspers and suction in hand, the large ischemic mass was manipualted and assessed. It became apparent that both ovaries were entirely normal and this ischemic mass was infact part of the right fallopnian tube.

With further manipulation, the site of attachement was found. Specifically, the proximal fallopian tube was in fact normal, however approximately midway long there was an transition point (which is suspecious for a torsion of the tube) where the remainder of the tube distally became ischemic and swollen into a large black cystic mass approximately 8 cm long in the widest (transverse) direction. No fimbrae could be identified as it was likely engulfed by the significant size of this presumed hematosalpinx.

Using the monopolar scissors, the large ischemic mass was cut at the site of the transition point. The scissors were then used to spot-burn the proximal end to ensure hemostasis. The was no blood loss with this procedure. Given the size of the complex mass, the decision to cut and evacuate its contents was made, such that it could be removed more easily. Again, the monopolar scissors were used to cut an opening into its contents and suction was used to evacuate it. Old, black, clotted blood was evacuated. A second incision was then made which revealed staw-like fluid, suggesting either a cystic component or normal flalopian tube serous fluid from the inside. After evacuating all the contents, the size of the mass had significantly reduced.

Attention was then turned to removing the mass from the abdomen. the right lower quadrant port size was extended to 10 mm using a scalple, and a 10 mm port was then inserted under direct visualization through the same opening in the anterior abdominal wall. An endocatch device was then introduced into the abdomen. The mass was then placed inside and the device was closed. The port was then removed being carful to hold on to the end of the endocatch bag, and with gentle manipulation, suction, and dissection above, and direct visualization laparoscopically from below, the mass was eventually teased out of the abdomen through the 10 mm opening. The specimen was then sent to pathology.

Following this, attention was turned back to the abdomen. Careful inspection of both ovaries, the left tube, the remaining proximaly right tube, and the uterus. Irrigation was used to remove the remaining blood in the pelvis. There was no active bleeding. After inspecting the entire abdomen one last time, the ports were removed one at a time under direct laparoscopic visualization. The CO2 gas was then allowed to escape and the subumbilical port was removed with the laparoscope in place allowing visualization of any possible bleeders. None were noted. The skin incisions were approximated with 3-0 monocryl sutures in a subcuticular manner. Hemostasis was again found to be adequate. The dilator was removed from the uterus and the tinaculum was removed from the cervix while assessing for any tinaculum site bleeding. None was noted. All sponges, instruments, and sharps were counted and correct at the end of the procedure. Estimated blood loss was minimal. The patient tolerated the procedure well and was transported to the recovery room in stable condition.