SAMPLE
O’CONNOR HOSPITAL
THOMAS LIN, M.D.
HYSTERECTOMY
____________________
ASSISTANT:
ANESTHESIOLOGIST:
HYUNKYO PARK, M.D.
OPERATION: Total abdominal hysterectomy, right salpingooophorectomy and left oophorocystectomy.
PREOPERATIVE DIAGNOSES:
1.
Myomata uteri.
2.
Right ovarian cyst.
3.
History of menorrhagia.
4.
History of severe anemia.
POSTOPERATIVE DIAGNOSES:
1.
Myomata uteri.
2.
Endometriosis.
3.
Right ovarian cyst.
4.
Left endometrioma.
5.
History of menorrhagia.
6.
History of severe anemia.
ANESTHESIA:
General.
OPERATIVE FINDINGS: The uterus was enlarged with big
submucosal myoma at the anterior fundus. The adnexa, on
the right side the ovary was enlarged with a clear cystic
mass about 2 cm attached to the pelvic wall with tubes.
The ovary surface showed edometriosis spots. The left
adnexa, the tube was normal. The ovary had a 1-cm
endometrioma on the surface. No adhesion on the left
adnexa. The rectum was attached to the back of the lower
part of the uterus and obliterated the cul-de-sac. No
ascites.
PROCEDURE: The patient was put in the supine position,
regular prep and sterile drape applied. Then a
Pfannenstiel incision was done to open the abdominal
cavity. A self-retaining retractor was put in the incision
wound and packed the bowel away. Then the uterus was held
up with a tenaculum and the above findings were noted.
Then I tried to free both adnexa from the broad ligament
close to the uterus to make a space for the surgery. Then
the left round ligament was clamped, cut and transfixed.
The anterior broad ligament was cut open and we went down
to the uterovesical flap area. Then the posterior leaf of
the broad ligament was perforated so the previous incision
of the anterior broad ligament around the round ligament
area and __________________ the ovarian ligament and then
the tube. Then #1 chromic catgut suture was threaded
through the hole and then we ligated only the ovarian
ligament and the tube area. Then the ligated area was
clamped, cut and transfixed again.
We then went to the right side. The right round ligament
was clamped, cut and transfixed and the anterior leaf of
the broad ligament was cut open and we went down to the
uterovesical flap area. Then the posterior broad ligament
was perforated with a finger to go through the anterior
broad ligament opening area. ________________ on the
ovarian ligament and then the tube. Through this hole a #1
chromic catgut suture was threaded through and we then
ligated along this area. The ligated area was clamped, cut
and then transfixed again.
Then the bladder was pushed down and the uterine vessels on
both sides were clamped, cut and then transfixed. Then
step by step with the Heaney clamp, the cardinal ligament
and the paracervical ligament was cut and transfixed. Then
the uterosacral ligament was clamped, cut and transfixed.
After this the vaginal mucosa was cut open and with the
Metzenbaum scissors the vaginal mucosa around the fornix
was cut so this way to remove the whole uterus with the
cervix away. On the vaginal stump was put a corner suture
on both sides and then the vaginal stump cut and in each
was put #1 chromic catgut suture in running locking
continuously in order to stop all the bleeders. Then one
stitch was put from the back of the middle artery vaginal
stump opening to reduce the opening.
Then the attention was moved to the right adnexa. Due to
extensive adhesions the retroperitoneal space was opened
and we exposed the infundibulopelvic ligament which then
was clamped, cut and transfixed. Then I tried to separate
the whole ovary with cyst away from the pelvic adhesions
and finally I was able to get the whole ovary with cyst
out. Some remaining attachment was cut and transfixed.
Then I went to the left adnexa. A small endometrioma was
noted so the endometrioma was cut open with the Bovie and
the contents were drained out and the inner side of the
capsule was cauterized with the Bovie. Then the small
opening was closed with #2-0 chromic catgut suture to stop
the bleeding.
After this I checked around to make sure there was no more
oozing or bleeding and then the pelvic peritoneum was
closed with #2-0 chromic catgut suture. The adnexal stump,
round ligament stump and the vaginal stump were put
extraperitoneally. Then irrigation was done of the pelvic
area to make sure everything was under control. No oozing
and no bleeding. Then the packing was removed, selfretaining retractor was removed, and then the abdominal
wall was closed layer by layer. The peritoneum was closed
by #2-0 chromic catgut suture. The muscular layer was
approximated in the midline. The fascia was closed by #0
Vicryl suture in running locking continuously. The
subcutaneous fat tissue was closed by #3-0 plain catgut
suture interruptedly. The skin was closed with metallic
staples.
The patient tolerated the procedure well.
No transfusion.
ESTIMATED BLOOD LOSS:
About 200 cc.