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REPORT OF OPERATION
DATE OF OPERATION: 10-28-93
PREOPERATIVE DIAGNOSIS:
1. Dysfunctional bleeding
2. Cervical dysplasia
3. Genital prolapse
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Transvaginal hysterectomy
SURGEONS: Ogman
ASSISTANT: Kofelt
ESTIMATED BLOOD LOSS: 800 cc's
ANESTHESIA: General by endotracheal intubation
ANESTHESIOLOGIST: Dr. Silva
FLUIDS: 4400 cc's of crystalloid
FINDINGS: Examination under anesthesia revealed the uterus to be approximately 8 weeks in size with no discrete masses; there were no adnexal masses palpable. Upon removal of the uterus, it was noted to be diffusely enlarged, approximately 8 weeks in size. The tubes and ovaries appeared normal and were left in situ.
COMPLICATIONS: Complications secondary to the estimated blood loss of 800 cc's with the hysterectomy, the anterior colporrhaphy was deferred in light of the patient's starting hematocrit of approximately 29.
Counts were correct x 3. The patient was taken in stable condition to the recovery room.
PROCEDURE: The patient was taken to the operating room where she was placed in the supine position. She had induction of general anesthesia by endotracheal anesthesia by intubation. There were two reports of her A.M. CBC on the chart, one was 30.6; the other was 41.6. Secondary to this discrepancy, a third CBC was sent; however, the results were not back by the time the case was initiated. Shortly after the patient had been intubated, the hematocrit came back at 28.6. It was elected to proceed with the procedure after discussion with anesthesia.
The patient was then placed in the dorsal lithotomy position; she was prepped and draped in the usual manner and the bladder was drained of clear urine. An examination under anesthesia was performed with findings as noted above. A weighted vaginal speculum was then placed posteriorly, a Raney retractor anteriorly. The surface was grasped on the anterior and posterior lips with single toothed cervical tenaculums. It was then brought down and easily came to approximately the introitus. The cervix was then circumferentially injected using a pitressin solution of 20 units of pitressin and 100 cc's of saline, and approximately 15 cc's of this solution were used. The posterior cul de sac was then identified and placing the posterior mucosa on traction, Mayo scissors were used to incise into the posterior cul de sac. Heaney hysterectomy clamps were then used to crossclamp the uterosacral ligaments bilaterally. These were transected and suture ligated using #0 vicryl. A second bite was then taken on each side with a Heaney hysterectomy clamp, transecting with Mayo scissors and suture ligating using #0 vicryl. These four sutures were tagged and held. At this point there was noted to be a considerable amount of oozing from the posterior vaginal cuff. An #0 chromic suture was then used to whipstitch the posterior cuff. This resulted in significant decrease in the amount of bleeding.
Attention was then turned anterior where the vaginal mucosa was incised connecting the posterior incision. A sponge stick as well as sharp dissection with scissors was then used to dissect the bladder off the anterior surface of the uterus; however, there was noted to be a significant amount of scarring secondary to previous C-section. Additional two bites were then taken on each side with Heaney hysterectomy clamp prior to entry into the anterior peritoneum. It was felt that the bladder was adequately dissected off the uterus to perform these bites. Each bite was transected using Mayo scissors and suture ligated using #0 chromic.
At this point, there was noted to be persistent increased scarring along the bladder flap. The peritoneum was now identified. A uterine sound was then placed in through the urethra into the bladder and the margin of the bladder was identified. Using sharp dissection, the peritoneum was then entered. A Rizzo retractor was then placed in through this incision in the peritoneum retracting the bladder out of the operative field. Serial bites were then taken using Heaney clamps along the broad ligament incorporating both the anterior and posterior peritoneum into each bite. There was noted to be a significant amount of oozing from the transected portion of the uterus despite having achieved the level of the uterine arteries on both sides. The fundus of the uterus was then reached. The utero-ovarian ligaments and vessels were then crossclamped and transected with the middle of the cervix and uterus. Each utero-ovarian pedicle was then free-tied with #0 vicryl followed by suture ligature of #0 vicryl. On visualizing the pedicles, they were noted to be hemostatic. The tubes and ovaries were visualized at this time and were felt to be normal in appearance. Secondary to the patient's age, it was elected to leave the ovaries in situ.At this point, the pedicles were visualized and there was noted to be no significant bleeding; however, there continued to be persistent oozing along the posterior vaginal cuff though there were no discrete bleeding sites noted. At this point, the estimated blood loss was approximately 700 cc's with the persistent oozing, and it was elected secondary to the patient's initial low hematocrit to defer the anterior colporrhaphy secondary to the risk of significant blood loss with anterior colporrhaphy necessitating transfusion.
The anterior peritoneum was then identified. The peritoneum was then closed in a purse-string suture of #2-0 chromic with care taken to avoid entrapment of bowel or omentum. The posterior cul de sac was reefed as high up as possible to obliterate the cul de sac. This suture was then tied down into place. Again the pedicles were visualized and noted to be hemostatic with no significant bleeding. The previously tagged and held sutures on the cardinal and uterosacral ligaments were separated. A free Meyer needle was then used to bring one strand of each out anteriorly through the vaginal mucosa and one posteriorly through the vaginal mucosa. These were then tied. This resulted in closure of the vaginal cuff transversely as well as cessation of any significant bleeding. A vaginal pack was then placed which had been coated in Dinestryl creme. A Foley catheter was placed with clear urine noted to be draining, with approximately 100 cc's noted.
The patient was awakened and taken to the recovery room in stable condition with no apparent complications.
Phun Webbe, M.D. |
