Clinical Note: Ms. _______________ is a 45 year old patient known to have progressing menorrrhagia in the context of an enlarged uterus recently seen on ultrasound. Her endometrial biopsy showed benign proliferative endometrial tissue without abnormality. The patient requested definitive management with a hysterectomy after discussing all possible medical options. Consent was signed in the office prior and all risks and benefits were reviewed.

Procedure Note:
Under GA in the dorsal lithotomy position, the patient was prepped and drapped in the usual sterile fashion. Beginning at the vagina, a foley catheter was inserted under sterile conditions and left in situ for the remainder of the case. A weighted speculum was then 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 and a Valchev manipulator/RUMI/V-Care/Hohl manipulator with a ceramic cup was inserted). The weighted speculum was then removed. Attention was then turned to the abdomen.

0.5% bupivicaine solution was used for infiltration of all port sites. Beginning in the subumbilical area, the skin was first infiltrated with ~ 2 cc of the bupivicaine solution, then a 10 mm incision was made through the skin with a #11 blade, and finally, the Veress needle was inserted uneventfully in the peritoneal cavity. The opening pressure was < 8 mmHg. The peritoneal cavity was insufflated with CO2 gas to a maximum pressure of 20 mmHg. The Veress needle was removed and a 10 mm trocar was introduced without difficulty through this site into the peritoneal cavity. The laparoscope was then introduced and confirmation of entry was made. Examination of the peritoneal cavity revealed no signs of injury from entry and normal anatomical structures. (Describe liver, GB, adhesions, bowels etc). The patient was then placed in steep Trendelenburg and three more 5 mm trocars were placed, one on the left and two on the right, in the standard technique, taking care to avoid the epigastric vessels. All trocars were placed under direct visualization with no inadvertent damage to underlying structures. The uterus was upheld from below and revealed a normal uterus and normal tubes and ovaries (Describe uterus/ovaries/tubes).



Once the bladder was appropriately dissected free from the lower anterior uterine segment and the tissues skeletonized, the uterine arteries were bilaterally clamped and ligated. Pedicles were checked and hemostatic. At the level of the (porcelain/plastic) cup of the uterine manipulator, the vaginal vault was incised circumferentially with a (monopolar J-hook/L-hook/Mahnes needle). The uterus (+/- tubes and ovaries) was delivered through the vagina and sent to pathology. A sterile glove was then placed into the vagina to form a pneumatic seal and all the pedicles as well as the cuff edges were examined. Hemostasis was achieved with bipolar cautery. The vaginal vault was then closed with a (V-Loc barbed stitch/Vicryl suture/Endo Loc/etc) being sure to avoid the bladder lateral pedicles. Following vault closure, an inspection of all areas was made to ensure hemostasis. All ports were removed under direct visualization and hemostasis noted. The final 10 mm port was then opened to release the abdominal gas and removed with the laparoscope inplace to visualize its removal. Using kochers to grasp the fascia within the 10 mm insition, a deep vicryl suture was placed to close to fascial defect being sure to avoid bowel. All the incision sites were then closed with 4-0 monocryl sutures in a subcuticular fashion.

At the end of the procedure, all sponges, instruments, and sharps were counted and correct. Estimated blood loss was (xxx) ml. The patient was taken to recovery in stable condition.