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1. INTRAUTERINE PREGNANCY AT 39-5/7 WEEKS GESTATION.
2. ARREST OF SECOND STAGE OF LABOR AND DESCENT.
3. RULE OUT ABRUPTION VERSUS UTERINE DEHISCENCE.
1. ARREST OF DESCENT.
2. LEFT UTERINE ARTERY LACERATION.
TITLE OF SURGERY: REPEAT LOWER-SEGMENT TRANSVERSE CESAREAN SECTION.
ESTIMATED BLOOD LOSS: 1000 CC.
FINDINGS: A living female infant, vertex, right occipitotransverse position, weight 6 lbs., 2722 gm, Apgar scores 9 and 9.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after her epidural, preparation, and Foley had been performed. The abdomen was prepped and draped and tested for analgesia. When found to be adequate, a repeat low-abdominal Pfannenstiel incision was made with the first knife and carried down to the fascia with a second knife. The fascia was cleared of subcutaneous tissue. Bleeding points were clamped with hemostats and Bovie coagulated. The fascia was incised in the midline and extended laterally with curved Mayo scissors. Kocher clamps were placed on the fascial edge, first anteriorly and then superiorly.
The rectus muscles were separated by sharp dissection. A 5-yard roll was placed over the superior Kocher clamps and placed over the head of the table for retraction. The rectus muscles were divided in the midline by sharp dissection. The parietoperitoneum was grasped with hemostats and carefully entered with a scalpel, and the incision extended with Metzenbaum scissors. The bladder blade was inserted. The visceroperitoneum was grasped with smooth pickups, entered with Metzenbaum scissors, and extended laterally. The bladder flap was created by gentle blunt dissection and placed behind the bladder blade. The lower uterine segment was noted to be quite thin; it was carefully incised with a scalpel and extended laterally with bandage scissors.
A living female infant was delivered from the vertex right occipitotransverse position. The head was noted to be wedged into the pelvis but was easily elevated with a hand. The baby was suctioned and cried immediately, and was handed to the pediatric team in attendance. There was some blood in the intrauterine cavity but no evidence of a dehiscence or an abruption.
The placenta was delivered manually. The uterus was explored with a wet lap sponge and found to be clear of membranes. There was marked bleeding coming from the laceration of the left uterine artery. The angles of the incision were sutured first with #1 chromic catgut suture; however, the laceration was noted to be lateral to the initial placement and a repeat angled suture was placed. The first layer of uterine closure was with running-locking #1 chromic catgut suture. The second layer was with imbricating #1 chromic catgut suture. An interrupted #1 chromic was also placed at the left angle to control hemostasis. The second layer of uterine closure was imbricating #1 chromic catgut suture. Hemostasis was carefully checked and found to be satisfactory. The bladder flap was closed with a running 2-0 chromic catgut suture. The fallopian tubes and ovaries were inspected and found to be normal bilaterally.
After correct lap and instrument counts, the peritoneum was closed with a running 2-0 chromic catgut suture. The rectus muscles were approximated in the low midline with an interrupted #1 chromic catgut suture. The Kocher clamps and 5-yard roll were removed. This fascia was closed with two running 0-Vicryl from lateral to midline. The subcutaneous tissue was approximated with interrupted 2-0 plain catgut. The scar on the lower incision of the skin was removed with Allis clamps, elevating it and excising it with a scalpel. Bleeding points were Bovie coagulated.
The subcutaneous tissue was approximated with 2-0 plain catgut. The skin was closed with staples. Urinary output was adequate and blood-tinged. The patient left to the recovery room in good condition.
PREOPERATIVE DIAGNOSES: SUDDEN ONSET OF HEAVY BLEEDING PER VAGINA WHILE PUSHING; ABRUPTIO PLACENTA.
POSTOPERATIVE DIAGNOSES: SUDDEN ONSET OF HEAVY BLEEDING PER VAGINA WHILE PUSHING; ABRUPTIO PLACENTA.
TITLE OF SURGERY: PRIMARY CESAREAN SECTION, LOW-TRANSVERSE UTERINE INCISION.
DESCRIPTION OF PROCEDURE: With the patient under satisfactory epidural anesthesia in the dorsal supine position, a quick preparation and draping for sterile abdominal surgery was carried out. A Pfannenstiel incision was made approximately 3 cm above the pubic bone. The subcutaneous layers and anterior rectus fascia were cut along the skin incision. Bleeding points were ignored except for some larger ones which were cauterized with a Bovie. The fascia was dissected sharply and bluntly away from the underlying rectus and pyramidalis muscles. The muscles were split in the midline and displaced bilaterally. The parietoperitoneum was incised in the midline from the edge of the bladder to the level of the umbilicus.
A bladder blade was placed in the incision. The visceroperitoneum on the lower uterine aspect was elevated, nicked, undermined bilaterally, and cut transversely. The peritoneal bladder flap was developed. A smiling-type incision was made with a scalpel blade on the lower uterine aspect and the endometrial cavity was entered in the midline. The incision was extended bilaterally with an index finger.
The infant's head was brought out from the pelvis and delivered with fundal pressure uneventfully through the incision. The nose and mouth were suctioned. The remainder of the infant's body was delivered. The nuchal cord was clamped twice and cut, and the infant was handed over to the pediatrician in attendance. It was a live female infant weighing 7 lbs. 14 ozs. She received Apgar scores of 8 and 9.
After securing cord blood in the usual manner, the placenta was delivered spontaneously. Examination of the placenta on the maternal side revealed a midportion which was covered with dark clots; approximately 1/4 of the margin had a similar appearance. The placenta looked heavily aged and calcified. The edges of the uterine incision were grasped with ring forceps. The uterus was delivered through the incision. The uterine incision was closed in two layers with #1 chromic. The first layer was done in a running-locking fashion and the second one in a horizontal Lembert-type fashion inverting the fascial edges. Hemostasis was satisfactory.
Examination of the adnexa revealed an approximately 5- to 6-cm cyst of Morgagni on the left adnexa in fairly close proximity to the oviduct in the ampullary infundibular area. The cyst was very carefully dissected and sent to the pathology lab for examination.
The raw area was reperitonealized with a 4-0 chromic suture. Hemostasis was satisfactory. The uterus was repositioned within the abdominal cavity. The visceroperitoneum was closed with 2-0 chromic suture. The pelvic and abdominal cavity were rinsed with copious amounts of saline solution. The abdominal wall was closed in layers as follows:
The parietoperitoneum was closed with 2-0 chromic. The muscles were approximated in the midline with 2-0 chromic. The anterior rectus fascia was closed in 0-Vicryl in running-locking fashion. The subcutaneous layers were closed with 3-0 plain gut. The skin was closed with 4-0 Prolene in a subcuticular manner reinforced with Steri-Strips. A dressing was placed over the incision.
Estimated blood loss in the delivery room was 700 cc. In labor and delivery, in a very short period of time before taking the patient to cesarean section, estimated blood loss was 350 cc. Replacement: See anesthesia notes. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
Severe Asherman's syndrome.
Severe Asherman's syndrome.
General endotracheal anesthesia.
Paragard T380 intrauterine device inserted.
DESCRIPTION: The patient was brought to the operating room and placed in the supine position, and given general anesthesia and intubated. She was placed in the dorsal lithotomy position and examination under anesthesia revealed a normal-sized anteverted uterus, no evidence of adnexal masses. She was then prepared and draped in the usual manner for simultaneous operative hysteroscopy and laparoscopy. These procedures were performed simultaneously after the bladder was catheterized and drained of about 200 cc of urine. A stab incision was made within the umbilicus through which a Veress needle was placed and 2 liters of carbon dioxide gas infused. Laparoscopic trocar and sleeve were inserted. Eventually a secondary puncture was created above the symphysis pubis. Vaginally a speculum was inserted into the vagina uterine cavity was explored. The scope was inserted a few centimeters into the endocervical canal into the lower uterine segment and was met with a wall of dense adhesions. Using blunt probes and flexible and rigid scissors, a cavity was eventually created and the limits of the uterotubal ostium or the cornua were determined by the use of a blunt probe, visualizing the movement of the probe in the cornual region of the uterus through the laparoscope, passed through the umbilicus. The left fallopian tube was actually cannulated with a Miles Novy cannula. Dye spill from the left tube was observed. Following the creation of the uterine cavity. Adhesions were dense and the procedure was involved. A Paragard T380 IUD was inserted and the position within the cavity verified by reinsertion of the hysteroscope.
Laparoscopically the uterus appeared to be normal in size. An old perforation site near the right cornua was identified. The left ovary was normal in size, oval in shape, white in coloration. Smooth surface was apparent. No adhesions or lesions were noted. The right ovary was normal in size, oval in shape, white in coloration. No adhesions or lesions noted. The left tube was normal in length, normal surface appearance, normal in size. The fimbria were delicate. As previously mentioned, this tube was cannulated and dye spill was seen. No adhesions or lesions noted. The right tube was normal in length. Normal surface appearance. Normal in size. This tube was not cannulated. The fimbria were delicate. No dye spill was seen. No adhesions were noted.
Following the procedure, the pelvis was irrigated. Hemostasis was found to be complete. Instruments were removed. Carbon dioxide gas was expelled. Incisions were closed with 4-0 Vicryl. The patient was reversed from anesthesia, extubated and transferred to the recovery room in satisfactory condition. She will receive Premarin therapy for the next morning prior to removing the IUD.
1. LEFT OVARIAN MASS.
2. ELEVATED CA-125 LEVEL.
1. BILATERAL OVARIAN ENDOMETRIOMAS.
2. PELVIC ENDOMETRIOSIS.
3. MYOMATA UTERI.
4. LEFT URETERAL OCCLUSION.
TITLE OF SURGERY:
1. EXAMINATION UNDER ANESTHESIA.
2. EXPLORATORY LAPAROTOMY.
3. LYSIS OF ADHESIONS.
4. RESECTION OF LEFT URETER.
5. EXTRAFASCIAL HYSTERECTOMY.
6. BILATERAL SALPINGO-OOPHORECTOMY.
ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.
INDICATIONS: The patient is a lovely 57-year-old female who presented with bilateral ovarian masses and an elevated CA-125 level. She was taken to the operating room for definitive surgery.
DESCRIPTION OF PROCEDURE: The patient was placed under general anesthesia in the dorsal lithotomy position. Examination revealed a large left 15-cm ovarian mass which appeared fixed, and fullness in the right adnexa. Fortunately, neither nodularity nor thickness was appreciated. The vagina was prepped and a Foley catheter inserted. The patient was placed in the supine position and her abdomen was prepped and draped.
A right paramedian incision was made from the symphysis to the umbilicus and was carried down to the anterior and posterior sheaths until the peritoneal cavity was entered. Peritoneal washings were then taken. Exploration of the upper abdomen revealed two normal kidneys and a smooth right lobe of the liver from the lateral margin to the ligamentum teres. There were at least two stones palpable in the gallbladder, at least 1 cm in diameter. Both diaphragmatic surfaces were smooth. The large and small bowel were grossly normal. Retroperitoneally, there were no enlarged or suspicious periaortic nodes from the level of the renal vessels to the bifurcation of the iliacs.
Within the pelvis, there seemed to be an enlarged uterus with a right ovarian endometrioma about 5 cm in diameter. There was a 14-cm semisolid fixed left adnexal mass which was adherent to the posterior wall of the uterus, the sigmoid colon, the posterior peritoneum, and the parietoperitoneum. As previously discussed with the patient, if neither ovary could be saved in this case with bilateral endometriomas, and given the myomata uteri, the surgical plan was to perform hysterectomy and bilateral salpingo-oophorectomy. Therefore, we began the surgery by freeing up the anterior attachments of the large left adnexal mass to the sigmoid colon.
We then went to the lateral pelvic side walls and were eventually able to find the round ligaments; these were identified and singly clamped and ligated with 0- Vicryl. We then developed a plane of the pubovesical cervical fascia, thereby freeing the bladder from the underlying cervix and vagina. Indigo carmine was given intravenously and was eventually seen to exit in the Foley catheter with no intraperitoneal or retroperitoneal spillage.
To facilitate dissection of the large left ovarian mass, we dissected the left ureter which was intimately adherent to the mass and occluded during its length. Therefore, a 1/4" Penrose drain was placed around the left ureter. This was completely dissected down to its entrance into the bladder. This then allowed us to find the infundibulopelvic pedicle from the left mass, and to doubly clamp and ligate this with 0-Vicryl. We continued to free up the large left pelvic mass and came to the uterine arteries on both sides. We were able to doubly clamp the uterine arteries. We then continued with single clamping of the cardinals, and then opened up the rectovaginal septum so we could cross-clamp the uterosacral ligaments. In this manner, we were eventually able to completely perform extrafascial hysterectomy, and the uterus, large left adnexal mass, right ovarian endometrioma, and tubes were removed as a single specimen. The endometrioma was then opened. As expected, it was completely filled with dark chocolate fluid.
Angled sutures were placed in the vagina with 0-Vicryl and reinforced. The cuff itself was then closed with continuous running 0-Vicryl suture. There were a number of bleeders in the pelvis which we then controlled with clips and hot cautery. On account of the patient's weight, the difficulty of the surgery, and the persistent small bleeders, it was elected to placed a 19-mm J-Vac drain deep in the cul-de-sac and to bring this out through the right lower quadrant. The pelvis was then copiously irrigated. When hemostasis was seen to be excellent. generous portions of Gelfoam were placed over all raw peritoneal surface areas.
Following correct lap pad, sponge, instrument, and needle counts, attention was turned to closure of the abdomen. Then 0-Prolene was used to place a row of interrupted horizontal mattress sutures through the anterior sheath. The anterior sheath itself was closed with two continuous running #1 PDS sutures starting inferiorly and superiorly and meeting in the lower 1/3 of the incision. The Prolene sutures were then tied. The subcutaneous tissue was then copiously irrigated with Ringer's, and the subcutaneous tissue approximated with interrupted 2-0 Monocryl sutures. The skin edges were approximated with 4-0 Monocryl subcuticular suture reinforced with 1/2" Steri-Strips and benzoin.
Estimated blood loss was 600 cc. Fluid replaced was 3400 cc crystalloid. Drains included a Foley catheter draining blue urine, and a cul-de-sac J-Vac. There were no complications The patient was sent to the recovery room in satisfactory condition.