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OB-GYN Samples

 

CESAREAN SECTION WITH TUBAL LIGATION

PREOPERATIVE DIAGNOSES:
1. A 39 plus 2/7 week intrauterine pregnancy.
2. Repeat cesarean (refused vaginal birth after cesarean section).
3. Multiparity, desires permanent sterilization.

POSTOPERATIVE DIAGNOSES:
1. A 39 plus 2/7 week intrauterine pregnancy.
2. Repeat cesarean (refused vaginal birth after cesarean section).
3. Multiparity, desires permanent sterilization.

OPERATION: Repeat low transverse cesarean section, vertical skin incision, and bilateral tubal ligation via Irving method.

ANESTHESIA: Spinal.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 750 ml.

INTRAVENOUS FLUIDS: 4800 ml LR.

URINE OUTPUT: 200 ml clear urine at the end of the procedure.

INDICATIONS: This is a 42-year-old G3, P1-0-1-1, at 39 plus 2/7 weeks, repeat cesarean section (refused VBAC), desires permanent sterilization (risks/benefits of procedure discussed with patient by attending physician, including risk of failure of 3 to 5/1000 with increased risk of ectopic gestation if pregnancy occurs).

FINDINGS: A female infant in cephalic presentation. Apgars 8/9. Weight 3750 g. Cord pH 7.30. Thick subcutaneous and subfascial scar tissue noted. Normal uterus, tubes, and ovaries.

PATHOLOGY: Segments of left and right fallopian tubes.

PROCEDURE: The patient was taken to the operating room where spinal anesthesia was found to be adequate and 2 g of Ancef was given. She was then prepared and draped in the normal sterile fashion in the dorsal supine position with a leftward tilt.

A vertical skin incision was then made with the scalpel and carried through the underlying layer of fascia. The fascia was incised in the midline and incision extended laterally with the scalpel. The superior aspect of the fascial incision was then grasped with the Kocher clamps, elevated, and the underlying rectus muscles dissected off with scalpel.

Attention was then turned to the inferior aspect of this incision, which in a similar fashion was grasped, tented up with the Kocher clamps, and the rectus muscles dissected off with scalpel. The rectus muscles were then separated in the midline and the peritoneum identified, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted and the vesicouterine peritoneum identified, grasped with the pickups, and entered sharply with the Metzenbaum scissors. The incision was then extended laterally and the bladder flap created digitally.

The bladder blade was then reinserted and the lower uterine segment incised in a transverse fashion with the scalpel. The uterine incision was then extended laterally with the bandage scissors. The bladder blade was removed and the infant’s head delivered atraumatically. The nose and mouth were suctioned with the bulb suction and the cord clamped and cut. The infant was handed off to the waiting pediatricians. Cord gases were sent.

The placenta was then removed manually. The uterus exteriorized and cleared of all clots and debris. The uterine incision was repaired with 2-0 Vicryl in a running fashion. A 2nd layer of the same suture was used to obtain excellent hemostasis.

Attention was then turned to the right fallopian tube. The Babcock clamp was then used to grasp the tube approximately 4 cm from the cornual region.  A 3-cm segment of the tube was then ligated with a 2 free ties of 2-0 Vicryl and excised. A Crile clamp was used to make a blunt incision in the uterine fundus and the proximal portion of the right fallopian tubal segment was sutured to the blunt incision on the uterus with a silk suture. Good hemostasis was noted.

The left fallopian tube was then ligated and a 3-cm segment excised in a similar fashion followed by a blunt incision in the uterine fundus with a Crile and the proximal segment of the left fallopian segment sutured into the uterine incision with silk suture. Excellent hemostasis was noted.

The gutters were cleared of all clots and the peritoneum was closed with a 2-0 Vicryl. Excess scar tissue was removed from both left and right lateral portions of the fascial incision with the scalpel. The fascia was reapproximated with PDS suture in a running fashion. The subcutaneous layer was reapproximated with 3-0 Monocryl in a running fashion. The skin was closed with staples.

The patient tolerated the procedure well. Sponge, lap, and needle counts were correct times 2. The patient was taken to the recovery room in stable condition.

 

Hysterectomy-TVT Suburethral Sling

PREOPERATIVE DIAGNOSIS:
1.  Fourth-degree cystocele.
2.  Third-degree uterine prolapse.
3.  Second-degree rectocele.
4.  Traction enterocele.
5.  Weakened pubocervical fascia.
6.  Potential genuine stress incontinence.
7.  Urethral hypermobility.  

POSTOPERATIVE DIAGNOSIS:
1.  Fourth-degree cystocele.
2.  Third-degree uterine prolapse.
3.  Second-degree rectocele.
4.  Traction enterocele.
5.  Weakened pubocervical fascia.
6.  Potential genuine stress incontinence.
7.  Urethral hypermobility.  
8.  Vaginal vault prolapse after the hysterectomy. 

OPERATION:
1.  Vaginal hysterectomy.
2.  Vaginal enterocele repair.
3.  Anterior colporrhaphy.
4.  A 4 x 7 cm dermal allograft placement in the anterior compartment. 
5.  Sacrospinous vaginal vault suspension. 
6.  Tension-free vaginal tape suburethral sling.
7.  Posterior colporrhaphy with perineorrhaphy. 

ANESTHESIA: Spinal.

ESTIMATED BLOOD LOSS: 500 ml.

COMPLICATIONS: None. 

PROCEDURE: The patient was brought to the operating room and placed in a sitting position and given spinal anesthesia.  She was then replaced in lithotomy position in gold post stirrups and prepped and draped in the usual fashion.  A marking stitch was placed through the vaginal apex and then I injected dilute 1:5 pitressin solution circumferentially around the cervix.  I then circumscribed the cervix sharply and gained entrance into the peritoneal cavity both anteriorly and posteriorly and then I clamped, cut, and suture ligated the uterosacral remnants, the cardinal ligaments, the uterine vessels, the broad ligaments, and finally the uteroovarian ligaments with delivery of the uterus and cervix.  The ovaries and tubes looked fine.  I had closed the enterocele defect with a single pursestring suture of 2-0 Gore-Tex bringing together the anterior tinea coli of the rectosigmoid, the lateral pelvic sidewall bilaterally, and the bladder reflection anteriorly.  This was tied and cut. 

I now grasped the anterior cuff and infiltrated underneath the anterior mucosa with the dilute pitressin.  I then undermined and transected the anterior mucosa in the midline up to the level of the bladder neck and dissected away the underlying endopelvic connective tissue back to the pubic rami bilaterally exposing the massive central cystocele.  I dissected back to the right ischial spine, the sacrospinous ligament.  I isolated the ligament with Breisky retractors and placed 2 sutures of 2-0 Gore-Tex through the ligament using the Miya hook, the first through the middle third and the second through the medial third.  The top portion of each Gore-Tex suture was fixed in a figure-of-eight fashion to the corresponding undersurface of vaginal mucosa and what would be the new vaginal apex and tied to itself to form a pulley stitch to tie down later on in the case.  Excess vaginal mucosa was trimmed.  I now reduced the central cystocele and brought the connective tissue from the sides together with 3 mattress sutures of 0 PDS.  Urethrocystoscopy was performed with a 70-degree lens and verified that blue dye was coming into both ureteral orifices without difficulty.  The bladder was now decompressed.  She had fairly extensive paravaginal defect on the right and the tissue on the left really did not look that good either, so I augmented this entire compartment with a donor graft.  I took a 4 x 7 cm piece of Alloderm, folded this half to form a 4 x 3 cm piece and sewed this in place so that the 2 anterior corners were attached to the arcus tendineus fascia of the pelvis at a level just beneath that of the bladder neck and the posterior 2 corners further posterolaterally.  The posterior midline of the graft was attached to the enterocele Gore-Tex suture.  These were all tied and cut.  I now closed the bottom half of the vaginal incision with a running interlocking suture of 2-0 Vicryl and then I tied down the sacrospinous tissue to directly appose the undersurface of vaginal mucosa to the ligament and these were tied and cut. 

Before I finished closure of the anterior wall, I went ahead with the TVT procedure.  The urethra was diverted off to the right with the rigid guidewire.  I introduced the TVT needle through the incision underneath the left pubic ramus and through the urogenital diaphragm, space of Retzius, rectus fascia, and out through a stab incision 2 cm left of midline.  The urethra was diverted off to the left and needle passage repeated on the right side.  Urethrocystoscopy was performed with 70-degree lens again to a capacity of 600 ml and then when no perforation or trauma was noted anywhere, the needles were pulled out and cut off and I adjusted tension on the tape at this volume while performing Credé maneuver.  The tape was brought up just to the point where leakage was still present but had largely slowed down and there was still a 0.25 to 0.5 cm of space between the tape and the posterior urethra.  At this level of tension, I held countertraction transvaginally while peeling the plastic sheath off the tape suprapubically.  The tape was cut beneath skin level. Mastisol and Steri-Strips were applied.  I now finished closing the remainder of the vaginal incision with the same running interlocking suture of 2-0 Vicryl.  Hemostasis was good.  All counts were reported as correct at the end of this part of the procedure. 

Attention was now turned to the gaping introitus and rectocele.  I infiltrated here with a dilute pitressin and then I excised a portion of perineum and vaginal mucosa sharply. I noted immediately that I had created an incidental enterotomy in the distal rectal area that was about 2 cm long.  So, I closed this carefully with a running suture of 2-0 Vicryl.  I now dissected away the underlying endopelvic connective tissue back to the pubic rami and anteriorly up above the rectocele, the rectocele was reduced in the midline and I brought the connective tissue from the sides together with several mattress sutures of 0 PDS.  She had a distal size specific defect, which I closed with an anterior imbrication of the distal rectum with 0 PDS.  Peroneal body was rebuilt with 0 PDS.  The vaginal mucosa I now closed with a running interlocking suture of 2-0 Vicryl and the perineum with a subcuticular suture of the same.  She had adequate caliber and length now and a Foley was in the bladder draining free-flowing blue urine.  A pack in the vagina.  Rectal exam was negative.  She tolerated it well and was brought to recovery in stable condition.  All counts were reported as correct. 

 

Bilateral Salpingo-oopherectomy

PREOPERATIVE DIAGNOSIS: Endometriosis, pelvic pain, retained ovaries after hysterectomy, significant pelvic fluid and adhesions.

POSTOPERATIVE DIAGNOSIS: Endometriosis, pelvic pain, retained ovaries after hysterectomy, significant pelvic fluid and adhesions. Evidence of residual endometriosis on the peritoneal cavity.

OPERATION: Laparoscopy with bilateral salpingo-oophorectomy, peritoneal biopsies, and cystoscopy.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 50 ml.

COMPLICATIONS: None.

FINDINGS: The patient had significantly adhered ovaries to the pelvic sidewall. She had extensive adhesions of the colon to the bladder and vaginal cuff. She had implants of endometriosis, 3 of that which were resected and removed. No other ones were seen. Washings were taken. Cystoscopy was performed because of the dense adhesions in the pelvis and good blue dye spillage was noted from both ureteral orifices and the bladder itself was intact.

PROCEDURE: After obtaining informed consent, the patient was to the operating room and general endotracheal anesthesia was induced. She was placed in a dorsal lithotomy position in Allen stirrups, careful not to put undue abduction of her hips or pressure on her perineal nerves. She was prepped and draped in the usual sterile fashion. A Foley catheter was inserted using sterile technique. Marcaine was used to infiltrate the infraumbilical area, and a 12-mm infraumbilical incision was carried to the abdominal wall in layers.

Upon entering the peritoneal cavity a blunt tipped trocar was placed. Vicryl sutures were placed on the superior and inferior leaves of the fascia. The abdomen was insufflated. We scanned the entire abdomen and pelvis and noted the above-mentioned findings. Using a combination of scissors and Harmonic shears, we carefully dissected all the adhesions of approximately a 45 minute period of colon to pelvic sidewall which was covering the ovary, colon to bladder, ovary to pelvic sidewall. The left ovary was brought up onto its pedicle, well away from the pelvic sidewall, and using the ligature, it was clamped, ligated, and divided. This left ovary was placed in a bag and brought out through the umbilical port.

Next, we dissected the right ovary free onto its pedicle. We then clamped, ligated, and divided that right ovary, placed into a bad and brought out through its umbilical port. The 3 separate endometriosis implants were dissected free with sharp dissection and brought out as separate specimens. We then gave the patient indigo carmine IV. We did a cystoscopy with the above-mentioned findings. Noted good dye spillage. There was no dye spillage in the peritoneal cavity. The abdomen and pelvis was washed with warm saline.

The Carter-Thompson closure device was used to close the fascia on the right lower quadrant manipulating port. It should be noted that both right and left lower quadrant operating trocars were placed under direct visualization. After closing the right lower quadrant port, we removed the 5-mm left lower quadrant port and then removed all the gas from the abdomen and removed the 10-mm umbilical port. We closed the fascia with 0 Vicryl suture. We placed 1 extra suture in addition to the 1 that had been previously placed. We then closed the skin with 4-0 Monocryl.

At the end of the case, all sponge and instrument counts were correct. The patient tolerated the procedure well and was taken to the recovery room in good condition.

THBSO

PREOPERATIVE DIAGNOSIS: Menorrhagia.

POSTOPERATIVE DIAGNOSIS: Menorrhagia.  

OPERATION: Total hysterectomy bilateral salpingo-oophorectomy.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: See anesthesia sheet.

INTRAVENOUS FLUIDS: See anesthesia sheet.

COMPLICATIONS: None.

FINDINGS: Normal upper abdomen including periaortic, nodes not palpable and liver normal. Normal appendix. Normal ovaries. Bilateral hydrosalpinx in the fallopian tubes. Multiple fibroids in the uterus. Normal ureters and bladder.  

INDICATIONS: This patient has had menorrhagia resulting in bleeding through her clothes every 2 weeks. D&C done preoperatively was benign, and the ultrasound done preoperatively revealed fibroids. The patient and I discussed options including no surgery and hysteroscopic thermal ablation and THBSO, possible appendectomy. A limited list of risks including infection and bleeding, injury to the uterus, ovaries, and tubes, bowel, bladder, blood vessels, nerves, ureters, anesthesia, transfusion with AIDS and hepatitis were all discussed. The patient understood and asked questions and agreed to the plan.  

PROCEDURE: The patient was brought to the operating room and I supervised her positioning on the table. She had sequential TEDs and antibiotics IV. A Foley was placed in the bladder after she was shaved, prepped, and draped and the balloon was tested. The Bookwalter retractor was used and we were careful to keep the ring off the underlying abdominal wall and the blades off the underlying muscles and nerves.

A transverse incision was made and dissection carried down through the fat and fascia. The rectus muscles were cut a third of the way from the midline and the inferior epigastric vessels were uninvolved. The peritoneum was entered bluntly. Findings were as noted above. We noted the ureters to be out of the operative region at the beginning and throughout the case repeatedly, particularly on the left side where we ultimately had to do several sutures to get control of blood loss at the left angle of the cuff. The round ligaments were doubly clamped, cut, and suture ligated. The broad ligaments opened and the infundibulopelvic ligaments identified, triply clamped, cut, and doubly suture ligated being sure not to involve the ureter. Vesicouterine peritoneum was cut, pushed inferiorly, and then the uterine vasculature was skeletonized, suture ligated, clamped, cut, and suture ligated again. Cardinal ligaments were sequentially clamped, cut, and suture ligated. An intrafascial technique was used to remove the cervix from the vagina. The uterus, ovaries, and tubes had previously been separated from the cervix to allow better visualization due to the large fibroids.

The intrafascial technique was used successfully and we then closed the cuff with interrupted 0 Vicryl suture. The uterosacral ligaments were very poorly developed and so we did not plicate them, as we were concerned about involving the ureters.

The appendix was completely normal and we left it in place. Irrigation was performed and there was excellent hemostasis and so we used continuous 0 Vicryl to close the fascia. Irrigation was performed and then we closed the skin with staples, covered it with padding and tape.

I spoke to the patient’s family postoperatively, she was taken to recovery in excellent condition.

 

D&C

PREOPERATIVE DIAGNOSIS:  

POSTOPERATIVE DIAGNOSIS:  

OPERATION: Dilatation and curettage, endometrial balloon ablation.

ANESTHESIA:   

INDICATIONS: The patient has severe menorrhagia which was not responsive to D&C and the patient did not want to take oral contraceptives.

PROCEDURE: The patient was prepped with Betadine and draped in a sterile technique in a dorsal lithotomy position. The anterior lip of the cervix was grasped with a tenaculum and the uterus was sounded to 8.5 cm anteverted and anteflexed. Dilatation with a #6 was performed and then suction curettage with a #6 suction curette lasting 3 minutes.

Following this, endometrial balloon ablation was performed using the Thermachoice apparatus. Balloon was emptied of air. It was inserted into the cavity of the uterus. It was filled up to 180 mmHg with about 30 ml of 5% dextrose. It was heated up to 87 degrees as per the protocol and as per the machine of 87 degrees centigrade. After treatment for 8 minutes without incident and the pressure dropping only to about 162 mm, the balloon was removed after appropriate cooling, the tenaculum was removed, and the patient was transferred to recovery room in satisfactory condition.

The patient tolerated the procedure well. Estimated blood loss was 10 ml.