Date: _______________
Surgeon: _______________
Assistant(s): _______________
Anesthesia: general
Anesthesiologist: Dr. _______________
PreOp Dx: Endometriosis, bilateral endometriomas
PostOp Dx: Same
Operation: Diagnostic Hysteroscopy, Laparoscopy, Dye Transit, bilateral ovarian cystectomy
Operative Findings:

EBL: minimal, less than 50 cc
Specimens: capsule of endometriomas
Complications: none
Disposition: Pt transferred to PACU, same day home discharge

Clinical Note: Ms. _______________ is a 30 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. With saline as the destension media, the hysteroscope was then inserted into the cervical os under direct visualization and the uterine cavity was then explored. The cavity appeared normal with a smooth and normal endometrial cavity and both ostia in the cornea identified. Following this, the hysteroscope was removed from the uterus and a uterine manipulator was placed into the cervix. Attention was then turned to performing the laparoscopy.

0.5% bupivicaine solution was infiltrated in the subumbilical area. A 10 mm subumbilical incision was made through the skin with a scalpal and the Veress needle was inserted uneventfully in the peritoneal cavity taking care to note an opening pressure of 8 mmHg. The peritoneal cavity was then 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 then explored, fluid, was seen in the cavity suggesting spillage from the hysteroscope. Presumed endometriomas were also seen bilaterally adjacent to each ovary. In keeping with the known diagnosis of endometriosis, countless powderburn spots were seen along the lateral, anterior walls, and on the fundus of the uterus. The ovaries were mobile, but limited due to the adjacent endometriomas. The tubes were also identified bilaterally and were normal in appearance. There was no signs of acute bleeding to suggest injury from the veress needle or trochar entry.

Following this, three 5 mm ports were placed. One in the patient's left lower quadrant, one in the right lower quadrant, and the last one approxiamtely a hand-length above the right. Each was inserted by first visually identifying a safe place on the abdominal wall with the laparoscope, taking care to avoid the inferior epigastrics, infiltrating the area with the bupivicaine solution under direct visualization, cutting the skin with the scalpal, and then inserting a 5mm trocar under direct visuaization, again taking care to not enter near any vessels or injury any peritoneal contents.

With graspers, suction, and monopolar scissors in hand, the first endometrioma on the patient's left was manipualted and assessed. Fenestration was performed, by performing a brief monopolar spot burn on the surface of the endometrioma. Once entry occured and spillage of its brown, old blood contents was visualized, the suction was used to drain the cyst. Although, for fertility purposes the plan was to leave the cysts in situ, the cyst capsule was easily released from the ovarian tissue without difficulty. The base of the capusle was left behind however as removing it would have required damaging the ovarian tissue below. The same process was the repeated on the endometria on the right. Again, the cyst capsule could easily be removed but the base was left behind to preserve ovarian tissue and reduce the chance of injury.

Following this, attention was turned to removing the cyst capsule fragments from the abdomin. To accomplish this, the camera was transfered to a 5 mm laparoscope and inserted through the 5 mm port on the patient's left side, while an endocatch bag was inserted into the 10 mm port. The fragments were easily placed into the bag and the apparatize was closed and removed through the 10 mm port without difficulty.

Once the fragments were collect, the dye transit test was performed. Using a methylene-blue, 20 cc was injected through the adaptor on the end of the uterine manipulator directly into the uterus. The laparoscope was then used watch for direct visualization of methylene blue. While initial entry into the pelvis with the hysterscope revealed significant spillage of saline, no methylene-blue was seen during the dye transit test.

Careful inspection of both ovaries, the tubes, the uterus, and the pelvis was performed.. Irrigation was used to remove the remaining small quantity blood/fluid in the pelvis and the enter pelvis was inspected to ensure hemostasis. 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.