austin_tycho | Operative Report

Preoperative Diagnosis
Pelvic pain, dysfunctional uterine bleeding, post endometrial ablation and bilateral tubal ligation.

Postoperative Diagnosis
Pelvic pain, dysfunctional uterine bleeding, post endometrial ablation and bilateral tubal ligation with endometriosis and adhesions left ovary to left uterosacral ligament, right fallopian tube to pelvic sidewall.

Additional Findings
Endometriosis on peritoneal sidewall with normal ovaries bilaterally.

Procedure
Laparoscopic supracervical hysterectomy with adhesiolysis, destruction of retroperitoneal endometriosis (harmonic scalpel).

Description of Procedure
The patient was prepped and draped in the usual sterile fashion, dorsal lithotomy position. She had indwelling uterine manipulator, indwelling bladder catheter. Attention was turned abdominally. A physoperitoneum was created, normal entry examination was noted, and a 5 mm trocar was placed suprapubically; right and left lower abdomen had 10-11 trocars placed. Using the Tripolar patented surgical device, the adhesiolysis was accomplished without difficulty. Ovarian suspensory ligaments and round ligaments were grasped bilaterally, transected and ligated, and the anterior peritoneal reflection was taken well below the field of dissection and ureters were identified along the median leaf of the broad ligament bilaterally.

Subsequently, the patient had skeletonization of the vessels. The uterine vessels were grasped bilaterally with the patented Tripolar device, juxtapositioned to the uterus itself and coapted with excellent ammeter display of tissue desiccation and visual conformation with division without bleeding. The dissection was taken down to the level of the uteroacral ligaments, bladder well below the field of dissection, and the harmonic scalpel was used to amputate the uterus. The 15 mm Gynecare tissue morcellator was used with extreme safety precautions to remove the specimen, which was sent for permanent pathologic evaluation. The patient subsequently had an "endosuture" after ablation of the endocervical canal, closing anterior peritoneum, the posterior peritoneum incorporating the endopelvic fascia over the cervical stump.

The hemostasis was excellent, no sign of bleeding, no sign of hematoma. The ovaries were normal bilaterally. Sidewall endometriosis had been excised and irrigated free using harmonic scalpel technique with no sign of bleeding, no sign of hematoma, care being taken to avoid sidewall structures. Low volume laparoscopy showed no sign of bleeding, no sign of hematoma. Ureters were seen coursing normally along the median leaf of the broad ligament bilaterally. Decision was made at this time to close. The scope was placed suprapubically. The umbilicus was viewed. There was no sign of bleeding. Fascial closure devices were used to close the two 10-11 sites with 2-0 Vicryl. Monocryl 3-0 was used on the skin, subcu and the patient was taken to the recovery room awake and alert. No complications. Prognosis is excellent.