Operation: Laparoscopically Assisted Vaginal Hysterectomy and Bilateral Salpingo-oophorectomy
Date: _______________
Surgeon: _______________
Assistant(s): _______________
Anesthesia: General with ET tube
Anesthesiologist: Dr. _______________
PreOp Dx:
- Menorrhagia
- Family history of breast and ovarian cancer
Operative Findings: Normal appearing tubes and ovaries, enlarged uterus
Clinical Note: Ms. _______________ is a 33 year old female with a history of progressing menorrhagia no longer amendible to medical treatment as well as a family history of ovarian and breast cancer. Consent for laparoscopically-assisted vaginal hysteretomy and bilateral salpingo-oophorectomy was obtained in the office and the risks of the procedure were explained.
Procedure Note:
Following the standard preoperative checklist, a general anesthesia was induced and the patient was placed in the dirsal lithotomy position. The abdomen, perineum, and vagina were prepped and draped in the usual fashion. A foley catheter inserted into the bladder and attached to straight drainage. After the initial preparation, the procedure commenced at the vagina.
With a speculum in place to visualize the cervix, the anterior and posterior lips of the cervix were separately grasped and clamped with ingle tooth tenaculums. The cervix was then dialted to a #6 hegar dilator and a small curet was then placed within the uterine cavity for manipulation purposes being careful not to puncture the uterus. The three instruments were then taped to one another to form a rudamentary manipulator. Attention was then turned to the abdomen.
Following infiltration with Marcaine, an infraumbilical incision was made and the Veress needle was gently advanced taking care to feel for the typical sensation of penetrating the peritoneum. With CO2 infiltration, an opening pressure of 7 mmHg was noted, and following this, a pneumoperitoneum of 15 mmHg was created. A 10 mm trocar was then passed through the same incision and the laparoscope was then inserted through the trocar sleeve. Visualization of the peritoneal cavity was then obtained and a brief inspection did not reveal any signs of complications from entry. Under direct observation, 5mm flank ports were then placed laterally on both the right and left sides taking care to respect anatomical landmarks and vessels. Once the placement of the ports was complete, the actual laparoscopic procedure began.
For Bilateral Salpingectomy
Beginning on the right side and distally along the length of the fallopean tube, the mesosalpinx was exposed by lifting the (tube/ovary) up towards the anterior abdominal wall. The mesosalpinx was then sequentially, clamped, ligated, and cut using the (ligasure/thunderbeat) working alongside the length of the tube and towards the cornua. Once the level of the cornua was reached (the tube was cut, removed through the port, and) attention was then turned to the other side. The same process was repeated on the left, sequentially clamping, ligating, and cutting the mesosalpinx being sure to not injure the adjacent ovarian tissue or other surrounding structures. The round ligament was then ligated and cut. Following this, the anterior leaf of the broad ligament was then taken down on the left side, dissecting down towards the peritoneal reflection at the base of the bladder and adjacent to the cervix. The same process was then repeated on the left side such that both sides met and the anterior leaflet had been appropriately skeletonized.
For Bilateral Salpingo-oophorectomy
Beginning on the right side, the Infundibular ligament was identified by lifting the tube towards the anterior wall of the abdomen. The ureter was confirmed along the pelvic side wall and peristalsis was noted. The (ligasure/thunderbeat) device was then used to clamp and ligate the IP ligament in three sequential bites. The IP was then cut middistance, again being sure to be clear of the ureter. Following this, the broad ligament was sequentially grasped, ligated, and cut in the direction of the round ligament hugging next to the fallopean tube. The round ligament was then ligated and cut. Following this, the anterior leaf of the broad ligament was then taken down on the left side, dissecting down towards the peritoneal reflection at the base of the bladder and adjacent to the cervix. The same process was then repeated on the left side such that both sides met and the anterior leaflet had been appropriately skeletonized.
To ensure excellent hemostasis prior to further manipulation, the pedicles of the cardinal ligament was then ligated and divided on each side using the (Ligasure/Thunderbeat).
Attention was then turned to the vaginal aspect of the surgery. The foley catheter was removed. A weighted speculum wa placed in the posterior aspect of the vagina and the (small curet/vaginal manipulator) was removed. The tenacula were repositioned anteriorly and posteriorly. A circumferential incision was made at the cervical vaginal reflection using cautery. This was undermind first anteriorly and a copotomy made without difficulty. This was then repeated posteriorly and a similar colpotomy made. Heaney retractors were then placed into each of these incisions. Beginning first on the patient's left, the uterosacral and cardnal ligament was clamped, divided, and suture ligated. Two bites were required to reach the previous dssection margin of the left side. THe same process was then repeated on the patient's right hand side, at which point, the specimen was completely freed. Once the sutures had been placed and the pedicles secured, the uterus along with both tubes and overies were removed transvaginally without difficulty. All pedicles were inspected and hemostasis was confirmed. The vaginal vault was then oversewn with a running nonlocking vicryl suture, securing first theposteror edge of the cuff followed by the anterior edge. Good hemostasis was obtained. Two figure-of-eight sutures were then placed across the vaginal vault to close it. Once these had been tied off, all sutures were trimmed, a wet sponge was placed in the vagina to pack it off while attention was again turned back to the abdomen. All instruments were removed from the vagina at this time.
Using the laparoscopic irrigation device, the abdomen was carefully irrigated and inspected to ensure complete hemostasis. Bipolar cautery was used on the pedicles to ensure they were hemostatic and secure. Once the entire abdomen was inspected , the water was suctioned and the instruments carefully removed. The ports were then removed under direct visualization being sure to note hemostasis of the port sites on removal. The incisions were then cloed with interrupted monocryl sutures. Estimated blood loss was less than 50 mL. The patient tolerated the procedure well, anesthesis reveresed, and the patient was taken to the recovery room in stable condition. All sponges, instruments, and sharps were counted and correct.