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Bilateral Tubal Ligation

PROCEDURE IN DETAIL:  After obtaining the appropriate consent and explaining the risks, benefits and alternatives to surgery, the patient was taken to the operating room.  She received subarachnoid block with excellent anesthetic result.  She was then prepped and draped in the usual sterile fashion for abdominal surgery.  An approximately 12-mm incision was made in a curvilinear fashion just beneath the umbilicus.  This was carried down to the fascia.  The fascia was elevated and incised in a transverse fashion.  The peritoneum was entered with the surgeon's finger.  Fallopian tubes were identified by positively identifying the fimbria distally.  An avascular segment of the mesosalpinx was identified and grasped with a Babcock clamp.  The mesosalpinx was opened and a 2-cm segment of tube was freed up.  Chromic #1 was used to ligate the ends of the freed-up segment of fallopian tube.  The intervening fallopian tube was excised and sent to pathology as a specimen.  Hemostasis was ensured.  Identical procedures were performed on both the right and left fallopian tubes.  All instruments were removed.  Counts were noted to be correct.  The peritoneum was closed along with the fascia with 0 Vicryl in a running continuous fashion.  The skin was reapproximated with a subcuticular stitch of 4-0 Vicryl.  A sterile dressing was applied.  The patient tolerated the procedure well and was transported to the recovery room in satisfactory condition.

 

Bilateral Tubal Ligation - Pomeroy

PROCEDURE IN DETAIL:  The patient was taken to the operating room, given spinal anesthesia, placed in the supine position, and prepped and draped in the usual sterile fashion.  An infraumbilical incision was made with sharp dissection down through abdominal wall layers.  The peritoneum was entered and extended, taking care to avoid the bowel.  The right tube was delivered through the incision and modified Pomeroy tubal ligation was performed using 0 plain ties.  The knuckles were excised.  Good hemostasis was noted on the cut edges. The left tube was delivered through the incision and ligated in modified Pomeroy technique using 0 plain ties.  The knuckles were excised.  Good hemostasis was noted.  The tubes were delivered back into the abdominal cavity.  The fascia was repaired with 0 Vicryl in a running fashion.  The skin was closed in a subcuticular closure with 3-0 Vicryl.  Estimated blood loss was less than 10 cc. Sponge and instrument counts were correct times two.

PROCEDURE IN DETAIL:  General anesthesia was induced and found to be adequate.  The abdomen was prepared with Betadine solution.  A vertical incision was made through the infraumbilical area and deepened down until the fascia was encountered.  The fascia was incised vertically and the peritoneum was incised.  Bleeding points were cauterized.  Retractors were inserted. The left fallopian tube was identified and elevated with a Babcock clamp. Plain gut 0 suture was placed through the mesosalpinx in figure-of-eight. Approximately 3 cm of fallopian tube was inside the suture and that part was excised.  The protruding endosalpinx was cauterized.  Additionally, 4-0 silk suture was placed distally and proximally to the excision site around the fallopian tube.  A similar procedure was performed on the opposite side. Both specimens were sent for pathology report.  There was no abnormal bleeding.  The peritoneum and fascia were closed together using 0 PDS continuous interlocking sutures.  The skin was closed with 4-0 Vicryl inverted interrupted sutures.  A sterile dressing was applied to the wound. Needle, sponge, and instrument counts were correct times three.

 

BTL - Hulka

PROCEDURE IN DETAIL:  After obtaining the proper consent, the patient was taken to the operating room, induced with a general anesthetic, placed in the supine position, and prepped and draped in the usual sterile fashion.  A Kronner uterine manipulator was inserted into the uterus for uterine manipulation.  The bladder was drained with a red rubber catheter.  Gloves were changed and an infraumbilical incision was made.  A Veress needle was inserted with generation of pneumoperitoneum.  A trocar and sleeve were inserted, through which the laparoscope was placed with good visualization of the pelvis.  The uterus, tubes and ovaries were identified.  The tubes were traced to their fimbriated ends and occluded using Hulka clips.  Two clips were placed on each tube with good application of each tube noted and good envelope sign developed.  She had a few adhesions in the cul-de-sac, but no endometriosis was noted in the anterior or posterior cul-de-sac.  The ovaries were normal.  The broad ligaments were intact.  There was no bleeding in the pelvis.  Estimated blood loss was less than 5 cc.  The laparoscope was removed.  Excess CO2 gas was expelled.  The sleeve was removed.  The incision was closed with 3-0 Vicryl in a subcuticular closure.  Instruments were removed from the vagina.  The patient tolerated the procedure well and was taken to recovery in stable condition.

C-Section

PROCEDURE IN DETAIL:  Spinal anesthesia was induced by the anesthesiologist and found to be adequate.  The abdomen was prepared with Betadine solution and draped in a sterile manner.  A transverse incision was made in the lower abdomen and deepened down through subcutaneous tissues.  Bleeding points were cauterized.  The fascia of the rectus muscle was encountered and incised transversely.  The fascia was dissected from the underlying abdominal muscles upward and downward.  The abdominal muscles were spread apart.  The peritoneum was identified and incised vertically.  A bladder blade was inserted and the vesicouterine peritoneum was incised transversely.  A bladder flap was created with fingers.  The bladder blade was reinserted and the lower uterine segment was incised transversely.  Amniotic fluid was clear.  The fetus was in cephalic presentation.   The head was delivered.  The nose and mouth were suctioned on the abdomen, and the rest of the body was delivered.  The baby was placed on the neonatal table where the awaiting pediatrician took further care of the baby.  The placenta was delivered manually.  An oxytocin drip and Ancef 2 g IV piggyback were given.  The uterus became firm and well contracted.  The uterine incision was closed in two layers using 0 Monocryl continuous interlocking sutures.  Hemostasis was good.  The uterus was moved back into the peritoneal cavity and the peritoneal cavity was washed out with lactated ringers to remove blood and amniotic fluid.  The peritoneum was closed using 2-0 Monocryl continuous sutures.  Instrument and sponge counts were correct times two.  The fascia was closed using 0 PDS continuous interlocking sutures.  The skin was closed using staples.  Blood loss was 700 cc.  The patient was transferred to the recovery room with stable vital signs.

 

PROCEDURE IN DETAIL:  After obtaining the proper consent, the patient was taken to the operating room where she was given spinal anesthesia and prepped and draped in the usual sterile fashion in the supine position on the operating table with a left lateral tilt.  A low vertical midline skin incision was made with sharp dissection down to and through abdominal wall layers.  The peritoneum was entered and extended, taking care to avoid the bladder and bowel.  A bladder flap was generated, followed by a low transverse uterine incision with delivery of a viable male with Apgar scores of 9 and 9.  The placenta was delivered manually.  The uterus was extraperitonealized and the endometrial cavity was cleaned.  The uterus was closed in layers, the first layer with #1 chromic in a running locking fashion, and the second layer with #1 chromic in a running imbricating fashion.  Good hemostasis was noted.  The bladder flap was repaired with 2-0 Vicryl in a running fashion.  The uterus was delivered back into the abdominal cavity.  Gutters were cleaned.  The parietal peritoneum was closed with 2-0 Vicryl in a running fashion.  The fascia was repaired with 0 PDS in a running fashion.  Subcutaneous tissue was reapproximated with 3-0 plain.  The skin was closed with staples.  Estimated blood loss was 800 cc.  Sponge and instrument counts were correct times two.  The patient tolerated the procedure well and was taken to recovery in stable condition

 

D & C


PROCEDURE IN DETAIL:  The patient was taken to the operating room and placed in supine position on the operating table.  Following adequate general anesthesia, she was prepped and draped in the usual fashion in the dorsal lithotomy position.  A weighted speculum was placed into the vagina.  The cervix was grasped with a double-toothed tenaculum.  The cervix sounded to 8 cm and readily admitted a 7-mm suction curet.  Endometrial contents were evacuated under suction.  This was confirmed with a small sharp curet. Following this, all instruments were removed from the vagina and the procedure was terminated.  The patient tolerated the procedure well and was returned to the recovery room in good condition.

 

LEEP Electrocautery Cone Biopsy

PROCEDURE IN DETAIL:  The patient was taken to the operating room, induced with general anesthesia, placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the vagina and good vaginal retraction was noted.  Using a size 20 x 8 LEEP excisional loop, excision of the transformation zone was performed.  Using a 10 x 10 loop, endocervical biopsy was then performed.  The transformation zone was removed entirely as noted by Lugol preparation of the cervix.  The cervical bed was cauterized with coagulation, with the cautery set on coag.  There was minimal to no bleeding.  Estimated blood loss was less than 5 cc.  There was no evidence of injury to the perineum, vagina, bowel or bladder.  The patient tolerated the procedure well and was taken to recovery in stable condition.

 

SUMMARY:  The patient was taken to the operating room and underwent sterile prep and drape in the usual fashion.  After induction of general anesthesia, she was placed in the dorsal lithotomy position and LEEP electrocautery cone biopsy was performed.  The tissue was sent to pathology.  The base of the defect was cauterized and hemostasis was noted to be good.  The cervix was packed with Surgicel and the patient was taken to the PAR in good condition.  Sponge and needle counts were correct.

 

TAH

TAH  PROCEDURE IN DETAIL:  After obtaining the proper consent, the patient was taken to the operating room, induced with a general anesthetic, and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made with sharp dissection down to and through abdominal wall layers.  The peritoneum was entered and extended, taking care to avoid the bladder and bowel.  The uterus was small and appeared to be normal.  The tubes were normal.  The round ligaments were suture ligated bilaterally and cut.  Anterior and posterior leaves of broad ligament were dissected.  The infudibulopelvic ligaments were crossclamped, cut, and suture ligated with #1 chromic in a Heaney suture.  Broad ligaments were then skeletonized down to uterine vessels and a bladder flap was developed with blunt and sharp dissection.  The uterine vessels were then crossclamped.  These were cut and suture ligated with #1 chromic in a Heaney suture.  Cardinal ligaments were clamped, and these pedicles were cut and suture ligated with #1 chromic in a Heaney suture.  Uterosacral ligaments were then crossclamped.  These pedicles were cut and suture ligated with #1 chromic in a Heaney suture.  The specimen was handed off the table.  The cuff was closed with 2-0 Vicryl in a running locking fashion.  Good hemostasis was noted.  A McCall's colpoplasty was performed using 2-0 Vicryl.   Angles were sutured using #1 chromic in a Heaney stitch.  The angles were everted with #1 chromic.   The pelvis was then copiously irrigated.  After assurance of good hemostasis, the laps were removed.  The self-retaining retractor was removed.   The omentum underlying the anterior parietal peritoneum was closed with 2-0 Vicryl in a running locking fashion.  The fascia was repaired with 0 PDS in a running fashion.  Subcutaneous tissue was reapproximated with 3-0 Vicryl, and the skin was closed with staples.   Estimated blood loss was 125 cc.  Sponge and instrument counts were correct times two.  The patient tolerated the procedure well and was taken to recovery in stable condition.

OPERATIVE NOTE:  The patient was taken to the operating room and placed on the table in supine position.  Following adequate general anesthesia, she was prepped and draped in the usual fashion.  A Pfannenstiel incision was made with a knife and carried to the level of the fascia, which was nicked and extended with Mayo scissors.  The incised portion of the fascia was elevated with Ochsner clamps and the midline raphe was trimmed away superiorly and inferiorly.  The rectus muscles were bluntly divided.  Dr. Meaney placed a suprapubic catheter into the bladder.  The peritoneum was entered sharply with Mayo scissors.  An O'Connor-O'Sullivan retractor was placed into the abdomen and the bowel was packed away.  There was a large mass of dense omental adhesions all along the right abdominal wall, encompassing the lateral pelvic sidewall up to the umbilicus.  This was most likely due to appendenctomy in the past.  These were all taken down with blunt dissection.  The uterus, tubes and ovaries appeared to be normal with the exception of an ovarian cyst noted on the left measuring approximately 2 cm.  Round ligaments were identified, clamped, cut and secured with 0 Monocryl in a Heaney stitch.  Rogers clamps were placed across the infundibulopelvic ligament, which were then cut and secured with 0 Monocryl in a fore-and-aft stitch.  A U-shaped incision was made over the vesicouterine peritoneum and the bladder was bluntly dissected forward.  Progressive bites with Rogers clamps were placed across the parametrial tissues containing the uterine arteries and veins, and ultimately carried to the level of the cardinal and uterosacral ligaments.  The cervix was amputated from the superior portion of the vagina.  The vaginal cuff was closed with 0 Monocryl in a running fashion after vaginal angle sutures of 0 Monocryl had been placed on each side.  The vesicouterine peritoneum was approximated with 0 Monocryl in multiple figure-of-eight sutures.  All instruments were removed from the abdomen.  Sponge and needle counts were correct.   Hemostasis was adequate.  The parietal peritoneum was closed with 0 Monocryl in a running fashion, as were the rectus muscles.  The fascia was closed with 0 PDS 2 in a running fashion.  Subscutaneous tissues were closed with 2-0 plain in a running fashion, and the skin was closed with skin staples.  The patient tolerated the procedure well and was returned to the recovery room in good condition with stable vital signs.

TVH

PROCEDURE IN DETAIL:  The patient was taken to the operating room, given anesthesia, placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the vagina and the anterior and posterior lips of the cervix were grasped with a thyroid clamp.  The cervix was injected with dilute epinephrine solution.  A circumferential incision was made about the portio and the anterior and posterior cul-de-sacs were entered. The uterosacral ligaments were crossclamped, cut, and suture ligated with #1 chromic in a Heaney suture.  The cardinal ligaments were then crossclamped.  These pedicles were cut and suture ligated with #1 chromic in a Heaney suture.  The uterine vessels were crossclamped.  These pedicles were cut and suture ligated with #1 chromic in a Heaney suture.  The broad ligaments were crossclamped. These pedicles were cut and suture ligated with #1 chromic in a Heaney suture.  The posterior fundus was delivered through the posterior cul-de-sac.  The round ligament and tubo-ovarian pedicles were crossclamped.  These pedicles were cut and suture ligated with #1 chromic, followed by a free-hand ligature of #1 chromic.  Good hemostasis was noted from each one of the pedicles.  The ovaries and tubes were inspected and found to be normal.  The angles were sutured using #1 chromic, incorporating the anterior vaginal mucosa to the posterior parietal peritoneum and posterior vaginal mucosa.  McCall culdoplasty was then performed to obliterate the cul-de-sac.  The cuff was closed with 2-0 Vicryl in a running locking fashion.  A Vag-Pack and Foley catheter were inserted.  Estimated blood loss was 110 cc.  Sponge and instrument counts were correct times two. The patient tolerated the procedure well and was taken to recovery in stable condition.