D&C - DILATATION AND CURETTAGE

PREOPERATIVE DIAGNOSIS: Missed first trimester abortion.

POSTOPERATIVE DIAGNOSIS: Missed first trimester abortion.

OPERATION PERFORMED: Dilatation and curettage.

SURGEON:John Smith, M.D.

ANESTHESIA GIVEN: General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE: This is a 29-year-old white female, gravida 4, para 1, abortus 2, who was at 12 week's gestation. One week ago, she had an ultrasound done which showed a viable pole, consistent with 7 weeks 5 days. Today, she has had spotting for 3-4 days. Cervix is closed. Uterus is boggy. Intravaginal ultrasound showed an 8-week embryo which was nonviable. The patient observed this and it was quite obvious that it was a nonviable embryo. She is taken to the operating room now for a dilatation and curettage procedure.

DESCRIPTION OF OPERATIVE PROCEDURE: With the patient in the supine position under a satisfactory level of general anesthesia with endotracheal intubation, the patient's legs were placed in the lithotomy position. She was prepped and draped in the usual sterile fashion. The urinary bladder was catheterized.

Examination revealed a retroverted boggy 12-week sized uterus. The cervix was grasped with a single-toothed tenaculum. The cervix would easily pass a #20 Hanks dilator. A 10-mm suction curet was placed and a large amount of tissue and blood were removed. The uterus then was sounded again to 11 cm. Total blood loss was about 75 cc.

The patient was awakened and taken to the postoperative recovery room in good condition.

CESAREAN SECTION

PREOPERATIVE DIAGNOSIS: Nonreassuring fetal heart rate pattern.

POSTOPERATIVE DIAGNOSIS: Nonreassuring fetal heart rate pattern.

OPERATION PERFORMED: Primary emergent cesarean section with a low transverse uterine incision.

SURGEON:John Smith, M.D.

ANESTHESIA GIVEN: General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE: This is a 19-year-old white female, gravida 1, estimated date of confinement 07/02/2004, who was admitted for induction secondary to post-datism. Her cervix was thick and closed. Cervidil was placed. Around 2:00 a.m., she began having decelerations and Cervidil was removed. Oxygen was started and the fetal heart rate pattern improved. However, we watched this very closely and she progressed to about 9 cm, but began having significant decelerations again. There was loss of variability and the decelerations appeared to be late decelerations. She was given Terbutaline intravenously as tocolysis and operating room crew was called for a STAT cesarean section.

DESCRIPTION OF OPERATIVE PROCEDURE: With the patient in the supine position, the abdomen was prepped with isopropyl alcohol. She was draped in the usual fashion with an Ioban drape. Crash induction of general anesthesia with endotracheal intubation was performed.

A Pfannenstiel skin incision was made and extended through the subcutaneous tissue to the fascia. The fascia was incised transversely. The underlying muscles were sharply and bluntly divided. Muscles were divided in the midline. The peritoneum was entered sharply. The anterior uterine peritoneum was incised transversely. A bladder flap was developed and a low transverse uterine incision was made with the knife and extended bluntly. The infant's head was delivered. There was a nuchal cord x 1 which was reduced. The infant's nasopharynx and choanae were suctioned with delivery of the body. The cord was doubly clamped and divided with delivery of the body. The infant was handed off to the waiting pediatrician. Apgar scores were 8 at one minute and 9 at five minutes. Cord blood was obtained. The placenta was manually removed. The uterus was exteriorized. The uterine cavity was explored and found to be free of retained secundum. The uterine incision was closed with a single layer of running, locking 2-0 Vicryl suture. The abdomen was evacuated of clots, sponges, and debris.

The muscles were reapproximated in the midline with interrupted 2-0 Vicryl sutures. The fascia was closed with running looped 0-PDS and 3-0 Vicryl subdermal sutures were placed. Skin was closed with staples. Sterile dressing was placed. The patient was awakened and taken to the postoperative recovery room in good condition, having tolerated the procedure well. Estimated blood loss was 600 cc. Sharp count and sponge count were correct.

EXPLORATORY LAPAROSCOPY

PREOPERATIVE DIAGNOSES: (1) Recurrent pelvic pain. (2) Pelvic mass. (3) History of recurrent adhesions.

POSTOPERATIVE DIAGNOSES: (1) Recurrent pelvic pain. (2) Pelvic mass. (3) History of recurrent adhesions. (4) Adhesions. (5) Abdominal pelvic growth.

OPERATION PERFORMED: (1) Exploratory laparotomy. (2) Bilateral salpingo-oophorectomy. (3) Enterolysis. (4) Removal of abdominal wall growth.

SURGEON: Abraham Lincoln, M.D.

ASSISTANT: Dolly Madison, Surgical Assistant.

ANESTHESIA GIVEN: General endotracheal anesthesia.

INTRAOPERATIVE FLUIDS: IVs 1000 cc Lactated Ringers Solution.

PACKS AND DRAINS: Foley catheter to bedside drainage.

ESTIMATED BLOOD LOSS: Minimal.

INDICATIONS FOR PROCEDURE: The patient had recurrent abdominal pelvic pain that had been treated conservatively on multiple occasions and had not led to resolution and was not acceptable to the patient's normal lifestyle. After discussing the options with the patient, she was admitted for removal of her tubes and ovaries.

INTRAOPERATIVE FINDINGS: The patient had adhesions present on the cecum and the descending colon. There were adhesions present on both adnexa and vaginal cuff. Separate from this on the abdominal wall, were inflammatory changes that were consistent with benign neoplastic change. The above operation was performed as described below.

DESCRIPTION OF OPERATIVE PROCEDURE AND TECHINQUE: The patient was placed in the supine position and was draped and prepped in the routine sterile manner.

A transverse lower abdominal incision was made entering the abdomen. Enterolysis was performed, dissecting within an avascular plane, taking care to stay away from the bowel wall. This was continued until the adhesions were completely freed. At the completion of the enterolysis, hemostasis was complete and there was no injury to surrounding structures. Attention was turned to the adnexa. These were lysed with their attachment to the pelvic sidewall and the vaginal cuff. The ovarian pedicles were isolated bilaterally, clamped, cut, and transfix suture ligated. The attachment to the vaginal cuff was isolated bilaterally, clamped, cut, and transfix suture ligated, removing the specimen and sending it for pathology. Hemostasis was complete.

Separate from the area of the pelvic dissection were inflammatory changes on the abdominal wall. These were consistent with benign neoplastic change, consistent with reaction to adhesions versus old endometriosis. These were removed by destructive process, taking care to treat the entire area, but staying away from surrounding structure. At the completion, there was no visible residual pathology present.

The procedure was completed. The incision was closed in a layered closure of 3-0 Vicryl suture on the peritoneum, intermittently locking PDS suture on the fascia, 3-0 Vicryl suture on the subcutaneous tissue, a subcuticular Prolene stitch on the skin. The final sponge and needle count was correct and the patient was taken to the recovery room in good condition.

ECTOPIC (TUBAL) PREGNANCY PLUS TUBAL STERILIZATION

DATE OF OPERATION:

PREOPERATIVE DIAGNOSES:
1. Possible ectopic pregnancy versus incomplete abortion.
2. Requests elective sterilization.

POSTOPERATIVE DIAGNOSES:
1. Right cornu ectopic pregnancy (interstitial tubal pregnancy, right side).
2. Requests elective sterilization.

OPERATION PERFORMED:
1. Suction dilatation and curettage.
2. Diagnostic laparoscopy.
3. Laparotomy with excision of right cornu portion of uterus and tube.
4. Left tubal ligation.

DESCRIPTION OF OPERATIVE PROCEDURE:
The patient was taken to the operating room and placed on the operating room table in the supine position. General anesthesia was initiated via endotracheal tube intubation without complications. The patient was placed in lithotomy, prepped and draped in the usual sterile fashion. A red rubber catheter was used to drain the bladder.

Following this, the cervix was visualized and grasped with a double-toothed tenaculum and gently dilated and a suction curet was done with only a minimal amount of tissue being removed. A gentle sharp curettage was then performed with, again, only a minimal amount of tissue. At this point, a HUMI uterine manipulator was put into place and we proceeded to the abdomen.

A small subumbilical incision was made and the Veress needle was passed into the peritoneal cavity with CO2 used to inflate the peritoneal cavity until approximately 3 liters were used and the liver edge was tympanic. Following this, a 5-mm trocar was inserted in the site. A video laparoscope was inserted and immediately, it was seen a large cornu pregnancy at the right horn of the uterus with it still being intact, but had the appearance of imminent rupture. The left tube and ovary appeared grossly normal. The decision was made immediately to perform a laparotomy. The scope was withdrawn. The 5-mm trocar was removed and the skin incision was closed with 4-0 Monocryl suture.

At this point, a laparotomy tray was opened and using a clean scalpel, a Pfannenstiel skin incision was made and was carried down through all superficial layers without difficulty until the fascia was encountered, which was then transversely incised and further dissected off the underlying rectus muscle. The rectus muscle was divided in midline in a vertical fashion to expose the underlying parietoperitoneum which was then opened bluntly with a hemostat. This was further opened with the Metzenbaum scissors.

Following this, an O'Connor-O'Sullivan retractor was put into place. The bowel was packed away and the uterus could be visualized, where a large cornu pregnancy was seen at the right region of the uterus horn. The left tube and ovary appeared normal. At this point, the left fallopian tube was grasped with a Babcock and elevated in the midsection. The base of this was tied with 0-Vicryl suture. An opening was made in which additional two sutures were passed, one on each side of the knuckle, tying the base of each side of the tube. The tube was then excised and the edges of the excised area were cauterized without any bleeding. The area was hemostatically intact.

Attention was then turned to the opposite side, using Babcocks to hold up the tube and also the uterus. A dilute Pitressin solution was first injected into the uterus surface near the cornu pregnancy. Care was taken to avoid large vessels at the ovarian ligament region. An elliptical incision was made with the scalpel. Following this, using the Bovie electrocautery instrument, the elliptical incision was taken down underneath the cornu ectopic region. Then using Heaney clamps, the portion of the tube on the right side approaching the uterine wall was clamped, cut, and suture ligated with 0-Vicryl suture with adequate hemostasis being noted. An additional clamp was then placed near the ovarian ligament region and the corner of the uterus where there was some bleeding. This was clamped, cut, and suture ligated with 0-Vicryl suture for adequate hemostasis. The cornu pregnancy was then removed with the Bovie electrocautery instrument and sent to pathology for assessment. Following this, cauterization was done of the bed to assure there was no residual ectopic and of which it was felt none was left from visualization.

Then using interrupted figure-of-eight sutures, the defect in the bed was closed with good hemostasis and approximation of the defect in the corner of the uterine wall. After this, the surface of the uterus was closed with continuous running, locking technique of 0-Vicryl suture with good approximation and hemostasis. Any small bleeding points were controlled with electrocautery. Copious irrigation was done and suctioned. The right ovary appeared grossly normal. The left ovary appeared grossly normal. The appendix was noted and appeared grossly normal. The ureter on the right side was below the area of the resection.

After irrigation was done, the area appeared to be hemostatically intact. Interceed barrier was placed over the site, hopefully to prevent any future adhesions. At this point, the lap pads and the self-retaining retractor were removed.

The fascia was closed with continuous running, locking technique with 0-Vicryl suture and good approximation and hemostasis along the incision of the fascia. The skin was closed with metallic staples. A Foley catheter had been inserted during the case and was left in place. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

CESAREAN SECTION PLUS TUBAL LIGATION

PREOPERATIVE DIAGNOSES: (1) Term pregnancy in active labor. (2) Previous cesarean section; for planned repeat cesarean section with tubal ligation.

POSTOPERATIVE DIAGNOSES: (1) Viable female infant; Apgar scores of 8 at one minute and 8 at five minutes - birth weight pending. (2) Surgically absent left tube and ovary.

OPERATION PERFORMED: Repeat cesarean section with right tubal ligation, low transverse uterine incision utilized.

ANESTHESIA: Spinal.

ESTIMATED BLOOD LOSS: 800 cc.

DRAINS: Foley catheter.

COMPLICATIONS: None.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was taken to the operating room and was placed in supine position after she had spinal anesthesia placed. A right hip tilt was placed. She was then prepped and draped in the usual sterile fashion.

Through the midline incision, the abdomen was opened in layers. The peritoneal cavity was entered without difficulty. A bladder flap was created in the lower uterine serosa and the uterus was incised transversely. This was extended laterally with bandage scissors.

The hand was placed into the uterine cavity and with fundal pressure, a viable female infant, Apgar scores of 8 at one minute and 8 at five minutes, was delivered. The cord was doubly clamped and cut. Cord blood was obtained. The placenta was manually extracted. The uterus was exteriorized. The uterine cavity was cleaned with a sponge until all membranes and mucus were removed. The uterine incision was closed with a running, locking suture of 0-chromic gut. After the closure, there was good hemostasis noted.

The left tube and ovary were surgically absent. The right tube and ovary were identified. The tube was identified by finding its fimbriated end. In the isthmic portion of the tube, it was elevated, and in the mesentery, an opening was made with cautery. Two free ties of 0-plain gut were placed through and an intervening segment of tube was tied off. That segment was excised and submitted to pathology. There was some minor oozing on the distal portion of the tubal stump and this was cauterized. Having established good hemostasis, the uterus was placed into the abdominal cavity. The cavity was washed and irrigated free of clots. The uterine incision itself was inspected and found to be hemostatic.

The incision was closed en masse with a running 0-PDS suture that started both at top and bottom and were tied in the midline. This en masse closure was accomplished. It appeared that on the right side, there was more scarring of the subcutaneous tissue than on the left and it would resulting in an uneven coaptation. Using electrocautery, the left subcutaneous tissue was incised parallel to the skin and the midline of the subcutaneous tissue. The subcutaneous tissue was reapproximated then with 3-0 plain gut. The skin was then closed with staples. All areas were washed and irrigated prior to closure.

The needle and sponge counts were correct at the end of the procedure. There was a clear yellow urine draining into the Foley catheter. The patient was then taken to the postoperative recovery room after a bandage had been placed over the incision.