Operative & Procedure Notes

After appropriate consent was obtained, the patient was taken to the operating room. She received Ancef in holding and was fitted with sequential compression stockings. She was placed under general anesthesia and then prepped and draped in the normal sterile fashion in the dorsal lithotomy position in candy-cane stirrups.

After a surgical pause was performed, the bladder was drained. A weighted speculum was placed in the posterior vagina. A Deaver retractor was placed along the anterior vaginal wall. The anterior lip of the cervix was grasped with a single tooth tenaculum, and a double tooth tenaculum was placed incorporating both the anterior and posterior lips of the cervix.

The cervical mucosa was then circumferentially infiltrated with a solution of vasopressin and bupivacaine. The cervix was circumferentially incised with the scalpel. The mucosa was then pushed cephalad from the cervix anteriorly. The posterior cul-de-sac was next entered sharply with the Mayo scissors. A suture of 0-Vicryl was placed to tag the posterior peritoneum to the posterior vaginal mucosa in the midline and held on to with a hemostat.

The uterosacrals were then in turn clamped with a Heaney clamp, transected and suture ligated with 0-Vicryl and tagged with hemostats.  A finger was placed around the bulk of the cervix and an anterior colpotomy was made with the Bovie scalpel directly in contact with the protective finger.  Deaver retractor was placed in this space.

The cardinal ligaments were then clamped, sealed, and transected with the energy sealing device device, bilaterally. Hemostasis was ensured.

An anterior colpotomy was made after identifying the vesicouterine peritoneal reflection with the Metzenbaum scissors. The Deaver was replaced with a Heaney retractor to protect the bladder and intraperitoneal entry was confirmed with visual inspection.

Serial pedicles along the broad ligament were then clamped, sealed, and transected, with the energy sealing device device.

The remaining portion of the broad ligaments were sealed and transected, freeing the specimen. The specimen was then sent to pathology.

***[The right fallopian tube was grasped at the proximal end with an Allis clamp and the distal end with another clamp. The energy sealing device device was then used to clamp, seal and transect the mesosalpinx until the fallopian tube was removed. Hemostasis was ensured. Same process was completed on the left side for removal of the left tube. Excellent hemostasis was noted. Both tubes were sent to pathology for permanent evaluation.]

***[The right ovary was grasped with a Babcock clamp and the tube with an Allis clamp. The energy sealing device device was used to clamp, seal and transect the infundibulopelvic ligament to remove tube and ovary. This was repeated on the left side. Hemostasis was ensured. Both tubes and ovaries were sent to pathology for permanent evaluation.]

Reinspection of the operative site revealed excellent hemostasis. The pelvis was irrigated with warm water and all pedicles were again noted to be hemostatic. The posterior peritoneum was then transfixed to the posterior vaginal mucosa with a running locked stitch of 0-Vicryl.

A modified McCall’s culdoplasty was then performed using a 0-Vicryl stitch, incorporating the bilateral uterosacrals. A second suture was used to form a figure-of-8 incorporating both uterosacrals and the lateral thirds of the posterior vaginal cuff.

The residual vaginal cuff was then closed with 0-Vicryl with a running stitch in an anterior to posterior direction. Hemostasis was again ensured.

The bladder was drained.

The patient was then taken out of the lithotomy position. She tolerated the procedure well and was taken to the recovery room awake and in stable condition. Sponge, lap, needle, and instrument counts were correct times two.

The patient received 2g Ancef IV in preoperative hold. She was taken to the operating room with IV fluids running and pneumatic compression stockings applied to both lower extremities. General endotracheal anesthesia was induced and found to be adequate. An exam under anesthesia was performed with findings as previously noted. She was prepped and draped in the normal fashion in low lithotomy with arms tucked at each side. A Foley catheter was inserted.

A uterine manipulator was placed. A vertical 5 mm skin incision was made in the umbilicus. A direct entry, optical trocar was then used to enter the abdominal cavity which was inflated with high-flow CO2. Immediate inspection of the contents revealed no trocar injuries.

An intra-abdominal survey revealed the findings as previously noted. Two 5 mm trocars were inserted under direct visualization in the right and left lower quadrants respectively, 2 cm medial to each anterior superior iliac spine. Steep trendelenburg position was obtained.

The (L/R) uterine cornu was grasped and traction applied towards the contralateral side. The infundibulopelvic ligament was identified and the ureter was identified following a normal course.

***[The infundibulopelvic ligament was clamped, sealed, and divided, hugging the ovary as much as possible.]

***[The Fallopian tube and utero-ovarian ligaments each were clamped, sealed and divided.]

The proximal round ligament was grasped and divided, and the broad ligament was entered. The anterior leaf of the broad ligament was clamped and sealed, and this incision was carried down to the vesicouterine peritoneum. The contralateral dissections of the peritoneum, Fallopian tube, utero-ovarian ligament, round and broad ligaments were carried out similarly. The bladder flap was developed with gentle blunt dissection. The posterior leaf of the broad ligament and underlying uterine vessels were sequentially clamped and sealed on each side.

The cervicovaginal junction was delineated with the ring of the uterine manipulator, and incised circumferentially with monopolar scissors. The uterosacral and cardinal ligaments were completely detached from the cervix. The uterus and cervix were removed through the vagina. The vaginal cuff was closed with Vicryl suture in a continuous running fashion from the vaginal approach. The uterosacral ligaments were incorporated into the closure.

The pelvis was irrigated and hemostasis confirmed at decreased insufflation pressure. All instruments were removed from the abdomen. Skin incisions were closed with Dermabond.

This case required assistance from a highly trained surgeon for intuitive retraction and knowledgeable feedback and direction in the accomplishment of this extremely difficult procedure.  The assistant performed retraction, suturing, tying and assistance in cognitive decision making as necessary.  The assistant surgeon was able to verify that excellent hemostasis was assured at each step.  This case would have been  very difficult to complete without the assistant.

Sponge, needle, and instrument counts were correct. The patient was returned to supine position, awakened, and transferred to recovery in stable condition.

After proper consent was obtained, the patient was taken to the operating room. She was placed under general anesthesia and then prepped and draped in the normal sterile fashion in the supine position. A Foley catheter was placed. She received preoperative antibiotics on call to the operating room. A surgical pause was performed.

An  Alexis-O retractor was placed into the incision and the bowel packed away with moist laparotomy sponges. Two Kelly clamps were placed on the cornua and used for retraction. 

***[The left fallopian tube was elevated with a Babcock clamp and the energy sealing device was used to seal and divide the tube up to the level of the uterine cornua. This is repeated on the right side.]

***[The left ovary was elevated with a Babcock clamp and the energy ceiling device was used to separate the infundibulopelvic ligament in the ovary and fallopian tube were sealed and divided up to the level of the uterine broad ligament. This is repeated on the right side.]

The round ligaments on both sides were clamped, transected, and suture ligated with the energy sealing device. The anterior leaf of the broad ligament was incised along the bladder reflection to the midline from both sides with Metzenbaum scissors. The bladder was gently dissected off the lower uterine segment and the cervix with a combination of sharp and blunt dissection.

The uterine arteries were skeletonized bilaterally, clamped, transected and suture ligated with the energy sealing device. Hemostasis was ensured. The uterosacral ligaments were clamped on both sides, transected and suture ligated in a similar fashion.

The cervix and uterus were amputated with Jorgensen scissors. The vaginal cuff angles were closed with figure-of-eight stitches of 0-Vicryl and were transfixed to the ipsilateral cardinal and uterosacral ligaments. The remainder of the vaginal cuff was closed with a running stitch of Monocryl. Hemostasis was ensured.

The pelvis was irrigated with warm water. All laparotomy sponges and instruments were removed from the abdomen.

The fascia was closed with running 0-Vicryl. The subcutaneous adipose layer was reapproximated with 3-0 Vicryl. The skin was closed with 4-0 Monocryl in a subcuticular fashion. Dermabond was placed along the length of the incision.

This case required assistance from a highly trained surgeon for intuitive retraction and knowledgeable feedback and direction in the accomplishment of this extremely difficult procedure.  The assistant performed retraction, suturing, tying and assistance in cognitive decision making as necessary.  The assistant surgeon was able to verify that excellent hemostasis was assured at each step.  This case would have been  very difficult to complete without the assistant.

The patient tolerated the procedure well and was taken to the recovery room awake and in stable condition. Sponge, needle, and instrument counts were correct X2.

After proper consent was obtained, the patient was taken to the operating room with IV running.  She was prepped and draped in the normal sterile fashion in dorsal lithotomy position using candy cane stirrups.  Time out was performed.  

In and out catheterization was performed with 100cc clear yellow urine.

The vaginal mucosa overlying the midurethra was grasped with Allis clamps and incised with a scalpel. Metzenbaum scissors were used to dissect to the pubic ramus on either side. A scalpel was used to make a puncture on the medial side of the obturator foramen on either side. The Obtryx curved device was then deployed per manufacturer’s direction on either side.

Cystourethroscopy was performed.  Entire bladder was noted to be intact with normal filling.  Efflux noted from bilateral urethral orifices. The cystoscope was removed and the bladder drained of cystoscopic fluid.  

The mesh from the TOT was then fitted and released. The vaginal mucosa over the mid-urethra was closed with a running locked suture of 2-0 Vicryl. The skin punctures were closed with Dermabond. 

The patient was then taken out of the lithotomy position. She tolerated the procedure well and was taken to the recovery room awake and in stable condition. Sponge, lap, needle, and instrument counts were correct times two.

After appropriate consent was obtained, the patient was taken to the operating room. She received Ancef in holding and was fitted with sequential compression stockings. She was placed under general endotracheal anesthesia and then prepped and draped in the normal sterile fashion in the dorsal lithotomy position in candy-cane stirrups.

After a surgical pause was performed, the bladder was drained. A weighted speculum was placed in the posterior vagina. A Deaver retractor was placed along the anterior vaginal wall.

The cuff of the vaginal vault was grasped bilaterally with Allis clamps.  0 Vicryl sutures were placed at the vaginal cuff where the residual uterosacral ligaments were and these were held onto with hemostats.  The vaginal cuff was infiltrated with the vasopressin solution containing bupivacaine.  A scalpel was then used to make a transverse incision and then this was tensed with Allis adair's and then dissection was undertaken to identify the peritoneum which was eventually entered with Metzenbaum scissors.  The peritoneum was tacked to the posterior vaginal cuff.  A long weighted speculum was placed.

Attention was then turned to the high uterosacral colpopexy. The uterosacral ligament was grasped about 5 cm above the vaginal cuff on the left side after packing the bowel back with a wet sponge. A 2-0 Vicryl suture was passed through the ligament twice and held on to. A 2-0 Prolene was passed higher and medial to this suture and held on to. This was repeated on the other side. The ureter was palpated on both sides and noted to be free from the ligament.

An anterior repair was then performed. The medial portion of the anterior vaginal wall was grasped with two Allis clamps and the mucosa was infiltrated with the previous vasopressin solution. The Metzenbaum scissors were used to dissect and undermine a plane medially up to the point of reflexion anteriorly of the bladder. The vaginal mucosa was incised medially. This tissue was then grasped with Adair clamps and dissected away with a combination of sharp and blunt dissection on both sides.

A scalpel was used to make a puncture on the medial side of the obturator foramen on either side. The Obtryx curved device was then deployed per manufacturer’s direction on either side.

Diagnostic cystoscopy was then performed. The bladder was noted to be intact with no signs of trauma or pathology throughout. Both ureteral orifices were identified and noted to efflux. The scope was removed.

The mesh from the TOT was then fitted and released. The vaginal mucosa over the mid-urethra was closed with a running locked suture of 2-0 Vicryl. The skin punctures were closed with Dermabond.

A suture of 2-0 Vicryl was then used to connect the lateral pubovesical connective tissue on either side together in a series of bites that was repeated in two layers. The excess vaginal mucosa was trimmed and the incision repaired with a locked suture of 0 Vicryl.

The previously retained prolene sutures from the uterosacral colpopexy were then connected to the anterior and posterior vaginal walls on the ipsilateral side. The retained Vicryl sutures were connected to the full thickness of the anterior and posterior vaginal walls on the ipsilateral side. A 0 Vicryl was then used to close the residual cuff. The uterosacral sutures were tied and cut, elevating the cuff upwards. The cuff closure suture was tied last.

The residual vaginal cuff was then closed with 0-Vicryl with a running stitch in an anterior to posterior direction. Hemostasis was again ensured.

The bladder was drained.

Two Allis clamps were then used to define the boundaries of a perineal repair. A Scalpel was used to incise a diamond shaped portion of vaginal mucosa and perineal skin and this tissue was removed. The clamps were then used to identify perineal muscles and these were brought together after dissection with two figures-of-8 of 0 Vicryl. A 2-0 Vicryl suture was then used to repair the skin and mucosa.

This case required assistance from a highly trained surgeon for intuitive retraction and knowledgeable feedback and direction in the accomplishment of this extremely difficult procedure.  The assistant performed retraction, suturing, tying and assistance in cognitive decision making as necessary.  The assistant surgeon was able to verify that excellent hemostasis was assured at each step.  This case would have been  very difficult to complete without the assistant.

The patient was then taken out of the lithotomy position. She tolerated the procedure well and was taken to the recovery room awake and in stable condition. Sponge, lap, needle, and instrument counts were correct times two.

Labor course: ***

She was eventually noted to be complete and began to push. She went on to deliver a vigorous *** infant over an intact perineum. No nuchal cord was noted. There was delayed cord clamping for about two minutes. Pitocin was bolused in the IV. The cord was doubly clamped and cut. The infant was attended to by nursery staff.

Apgars were *** and *** at one and five minutes respectively. Weight was ***.

The placenta spontaneously delivered and was found to be intact, with a three vessel cord. Massage of the abdomen revealed the fundus to be firm. Inspection of the perineum revealed no midline laceration. No other obstetric lacerations were noted. Reinspection of the perineum revealed excellent hemostasis and there was good uterine tone. Mother and infant remained in the room postpartum in stable condition. Sponge, lap, and needle counts were correct.

Labor course: ***

She was eventually noted to be complete and began to push. She went on to deliver a vigorous *** infant over an intact perineum. No nuchal cord was noted. There was delayed cord clamping for about two minutes. Pitocin was bolused in the IV. The cord was doubly clamped and cut. The infant was attended to by nursery staff.

Apgars were *** and *** at one and five minutes respectively. Weight was ***.

The placenta spontaneously delivered and was found to be intact, with a three vessel cord. Massage of the abdomen revealed the fundus to be firm. Inspection of the perineum revealed a *** degree [midline, periurethral] laceration which was repaired with a 2-0 Vicryl suture in a normal fashion. No other obstetric lacerations were noted. Reinspection of the perineum revealed excellent hemostasis and there was good uterine tone. Mother and infant remained in the room postpartum in stable condition. Sponge, lap, and needle counts were correct.

After appropriate consent was obtained, the patient was taken to the operating room where adequate regional anesthesia was ensured and she was placed in the supine position. She received appropriate antibiotics on call to the operating room. Foley catheter was in place. Fetal heart tones were noted to be normal. The patient was prepped with chlorhexidine in the standard fashion and draped. A surgical pause was performed.

A straight, transverse, Joel-Cohen style incision was made with the scalpel 3 cm above the symphysis pubis. The incision was carried down to the underlying fascial tissue with the scalpel. The fascia was incised in the midline. The fascial incision was extended laterally with blunt dissection. The midline peritoneum was identified and entered bluntly. The peritoneal incision was extended laterally with blunt dissection.

A low transverse incision was made across the uterus. This incision was extended with cephalocaudad tension. Membranes were ruptured sharply. The fetal vertex was palpated, elevated to the hysterotomy, and delivered. The rest of the body delivered with ease onto the operative field.

The cord was doubly clamped and cut and the infant was handed to awaiting nursery staff. Pitocin was bolused in the IV solution. The placenta was massaged from the uterus and removed. It was noted to be intact with a three vessel cord. The uterus was then exteriorized from the abdomen and cleared of all clots and debris with a laparotomy sponge. The bladder blade was replaced. The hysterotomy was then repaired in a running locked fashion using 0-chromic suture. Excellent hemostasis was noted.

The uterus was then returned to the abdomen. The hysterotomy was re-inspected and excellent hemostasis was again noted. The fascia was reapproximated with 0 Vicryl suture. The subcutaneous fat was reapproximated with 2-0 plain gut. The skin was reapproximated with 3-0 Monocryl on a Keith needle. Dermabond  was applied externally.

The patient tolerated the procedure well and was taken to recovery in stable condition.

Sponge, lap, and needle counts were correct times two.

After appropriate consent was obtained, the patient was taken to the operating room where adequate regional anesthesia was ensured and she was placed in the supine position. She received appropriate antibiotics on call to the operating room. Foley catheter was in place. Fetal heart tones were noted to be normal. The patient was prepped with chlorhexidine in the standard fashion and draped. A surgical pause was performed.

A skin incision was made with the scalpel at the site of the previous skin incision. The incision was carried down to the underlying fascial tissue with the scalpel. The fascia was incised in the midline. The fascial incision was extended laterally with blunt dissection and sharp dissection. The midline peritoneum was identified and entered bluntly. The peritoneal incision was extended laterally with blunt dissection.

A low transverse incision was made across the uterus. This incision was extended with cephalo-caudad tension. Membranes were ruptured sharply. The fetal vertex was palpated, elevated to the hysterotomy, and delivered. The rest of the body delivered with ease onto the operative field.

The cord was doubly clamped and cut and the infant was handed to awaiting nursery staff. Pitocin was bolused in the IV solution. The placenta was massaged from the uterus and removed. It was noted to be intact with a three vessel cord. The uterus was then exteriorized from the abdomen and cleared of all clots and debris with a laparotomy sponge. The bladder blade was replaced. The hysterotomy was then repaired in a running locked fashion using 0-chromic suture. Excellent hemostasis was noted.

The uterus was then returned to the abdomen. The hysterotomy was re-inspected and excellent hemostasis was again noted. The fascia was reapproximated with looped PDS suture. The subcutaneous fat was reapproximated with 2-0 plain gut. The skin was reapproximated with 3-0 Monocryl on a Keith needle. Dermabond  was applied externally.

The patient tolerated the procedure well and was taken to recovery in stable condition.

Sponge, lap, and needle counts were correct times two.

After appropriate consent was obtained, the patient was taken to the operating room where adequate regional anesthesia was ensured and she was placed in the supine position. She received appropriate antibiotics on call to the operating room. Foley catheter was in place. Fetal heart tones were noted to be normal. The patient was prepped with chlorhexidine in the standard fashion and draped. A surgical pause was performed.

A straight, transverse, Joel-Cohen style incision was made with the scalpel 3 cm above the symphysis pubis. The incision was carried down to the underlying fascial tissue with the scalpel. The fascia was incised in the midline. The fascial incision was extended laterally with blunt dissection. The midline peritoneum was identified and entered bluntly. The peritoneal incision was extended laterally with blunt dissection.

A low transverse incision was made across the uterus. This incision was extended with cephalo-caudad tension. Membranes were ruptured sharply. The fetal breech was elevated to the level of the hysterotomy. The breech was then easily delivered with fundal pressure. The long bones of the lower extremities were splinted and delivered atraumatically using a modified Pinard maneuver. The fetus was delivered to the level of the axilla. The anterior upper extremity was then splinted and swept across the fetal chest and delivered atraumatically. The infant was then rotated 45 degrees and the other upper extremity was delivered in a similar fashion atraumatically. The fetal head was then flexed and delivered using a modified Mauriceau–Smellie–Veit maneuver.  

The cord was doubly clamped and cut and the infant was handed to awaiting nursery staff. Pitocin was bolused in the IV solution. The placenta was massaged from the uterus and removed. It was noted to be intact with a three vessel cord. The uterus was then exteriorized from the abdomen and cleared of all clots and debris with a laparotomy sponge. The bladder blade was replaced. The hysterotomy was then repaired in a running locked fashion using 0-chromic suture. Excellent hemostasis was noted.

The uterus was then returned to the abdomen. The hysterotomy was re-inspected and excellent hemostasis was again noted. The fascia was reapproximated with 0 Vicryl suture. The subcutaneous fat was reapproximated with 2-0 plain gut. The skin was reapproximated with 3-0 Monocryl on a Keith needle. Dermabond  was applied externally.

The patient tolerated the procedure well and was taken to recovery in stable condition.

Sponge, lap, and needle counts were correct times two.

The patient was taken to the operating room where her epidural was bolused and found to be adequate. She was then placed in a supine position and prepped and draped in the normal sterile fashion after her bladder was emptied. A surgical pause was performed.

An 18 mm intraumbilical incision was made along the inferior curvature of the umbilicus. This was carried out sharply through the subcutaneous tissues. The fascia was grasped with a Kocher clamp and elevated and entered sharply. The peritoneum was entered bluntly and noted to be free of any adhesions.

The patient was airplaned to the left side. The Yankauer suction tip was used to glide behind the uterus and off to the side to elevate the right fallopian tube to the incision. The right fallopian tube was then identified, grasped, and elevated with a Babcock clamp. The tube was followed out to the fimbriated end. The tube was then grasped with the Babcock clamp about 3 cm from the cornu. The Metzenbaum scissors were used to pierce the mesosalpinx in the avascular portion and create a window. Sutures of plain gut suture were then used to ligate the distal and proximal portions of this segment of tube, which was then excised. Hemostasis was noted.

This was repeated on the opposite side. The tubal segments were sent to pathology.

The fascia was then closed with #0 Vicryl on a UR-6 needle. The skin was reapproximated with Dermabond. Sponge, lap, needle and instrument counts were correct X2. The patient tolerated the procedure well and she was taken to the recovery room awake and in stable condition.

After proper consent was obtained, the patient was taken to the operating room. She was placed under general endotracheal anesthesia. She was then prepped and draped in the normal sterile fashion in the supine position..   Patient urinated just prior to transport to the OR. A surgical pause was performed.

A vertical 5 mm skin incision was made in the umbilicus. A direct entry, optical trocar was then used to enter the abdominal cavity which was inflated with high-flow CO2. Immediate inspection of the contents revealed no trocar injuries.

Immediate inspection of the abdominal cavity revealed normal pelvic and upper abdominal anatomy, including a normal appearing appendix and gallbladder. An additional 5 mm trocar was placed suprapubically under direct visualization. Steep Trendelenburg position was obtained.

The Filshie clip applicator was then advanced through the second trocar sleeve and the patient’s left fallopian tube was identified and followed out to the fimbriated end. The clip was applied in a perpendicular fashion across the entire width of the tube in the mid-isthmic area approximately 3 cm from the cornua. Hemostasis was noted in the mesosalpinx. The Filshie clip applicator was then reloaded and the patient’s right tube manipulated in a similar fashion with easy application of the Filshie clip.

The instruments were then removed from the patient’s abdomen after removing the insufflated gas. The two skin incisions were then closed with dermabond.

The patient tolerated the procedure well and was taken to the recovery room awake and in stable condition. Sponge, lap, needle, and instrument counts were correct x 2.

After proper consent was obtained, the patient was taken to the operating room. She was placed under general endotracheal anesthesia. She was then prepped and draped in the normal sterile fashion in the dorsal supine position. A surgical pause was performed.

A vertical 5 mm skin incision was made in the umbilicus. A direct entry, optical trocar was then used to enter the abdominal cavity which was inflated with high-flow CO2. Immediate inspection of the contents revealed no trocar injuries.

Immediate inspection of the abdominal cavity revealed normal pelvic anatomy.

One additional 5 mm trocar was inserted under direct visualization in the right lower quadrant, 2 cm medial to the anterior superior iliac spine. Steep Trendelenburg position was obtained.

The energy sealing device was used in serial bites to seal and divide the tube away from the mesosalpinx, closely hugging the tube. Finally, the tube was transected near the cornu. Hemostasis was ensured.

This process was repeated on the contralateral side.

The tubes were removed through the trocar site. Hemostasis of the operative site was again ensured. The instruments and trocars were then removed from the patient’s abdomen after removing the insufflated gas. The two skin incisions were then closed with dermabond.

The patient tolerated the procedure well and was taken to the recovery room awake and in stable condition. Sponge, lap, needle, and instrument counts were correct x 2.

After proper consent was obtained, the patient was taken to the operating room. She was placed under general endotracheal anesthesia. She was then prepped and draped in the normal sterile fashion in the dorsal lithotomy position in yellow-fin stirrups. The bladder was drained. A surgical pause was performed.

A sponge stick was placed in the vagina under the cervix.

A vertical 5 mm skin incision was made in the umbilicus. A direct entry, optical trocar was then used to enter the abdominal cavity which was inflated with high-flow CO2. Immediate inspection of the contents revealed no trocar injuries.

Immediate inspection of the abdominal cavity revealed ***.

Two additional 5 mm trocars were inserted under direct visualization in the right and left lower quadrants respectively, 2 cm medial to each anterior superior iliac spine. Steep Trendelenburg position was obtained.

The tube was grasped at the distal end with an atraumatic grasper and elevated. The energy sealing device was used in serial bites to seal and divide the tube away from the mesosalpinx, closely hugging the tube. Finally, the tube was transected near the cornu. Hemostasis was ensured.

This process was repeated on the contralateral side.

A 5 mm endocatch bag was used to gather up the specimen and this was removed. Hemostasis of the operative site was again ensured. The instruments and trocars were then removed from the patient’s abdomen after removing the insufflated gas. The three skin incisions were then closed with dermabond. The instrumentation was removed from vagina with no bleeding noted.

The patient tolerated the procedure well and was taken to the recovery room awake and in stable condition. Sponge, lap, needle, and instrument counts were correct x 2.

Patient was placed under general anesthesia, placed in supine position, and prepped and draped in the normal sterile fashion. A surgical pause was performed.

A vertical 5 mm skin incision was made in the umbilicus. A direct entry, optical trocar was then used to enter the abdominal cavity which was inflated with high-flow CO2. Immediate inspection of the contents revealed no trocar injuries.

Immediate inspection of the abdominal cavity revealed ***.

 A 5 mm skin incision was made in the right and left lower quadrants with 5 mm trocars advanced under direct visualization. The energy sealing device was used to transect the right IP ligament removing the ovary and fallopian tube. Hemostasis was achieved. An endoscopic bag was advanced into the abdomen and the right ovary and fallopian tube were removed. In order to removed the ovary through the small skin incision, the ovarian cyst was ruptured and drained while inside the endoscopic bag.

***This was repeated on the other side.

Hemostasis was again assured.Trocars were removed from abdomen. Abdomen was exsufflated of gas. Left lower quadrant skin incision was reapproximated with a JR-6 Vicryl dermabond. The remaining 2 skin incisions were reapproximated with dermabond. Patient tolerated the procedure well and was taken to recovery in stable condition.

Other Vaginal Surgeries Operative Notes

Suction dilation and curettage  

After proper consent was obtained, the patient was taken to the operating room. Patient urinated just prior to transfer to the operating room. She received 100mg of PO doxycycline prior to the procedure. The patient was placed under general anesthesia without difficulty; she was then prepped and draped in the normal sterile fashion in the dorsal lithotomy position utilizing candy-cane stirrups. Time-out was performed.

A bi-valved speculum was placed in the vagina. Anterior lip of the cervix was grasped with a tenaculum. The cervix was gently dilated to allow passage of a 9mm suction curette. Several passes with the suction curette were used to remove blood and products of conception. A gentle sharp curettage was then performed. Several more passes with the suction curette were performed until very minimal blood and no further products of conception were removed. All instruments were removed from the vagina.   Bimanual massage of the uterus allowed for excellent hemostasis.  Sponge lap and instrument counts were correct x2. Patient was transferred to recovery awake and in stable condition.

Hysteroscopy, D&C

After proper consent was obtained, the patient was taken to the operating room with IV running.  Pt urinated just before transport to the operating room. She was prepped and draped in the normal sterile fashion in dorsal lithotomy position using candy cane stirrups.  Time out was performed.  

A bivalve speculum was placed in the vagina.  The anterior lip of the cervix was grasped with a single tooth tenaculum.  The cervix was then sequentially dilated to #18 hanks dilator.  Hysteroscope was then inserted.  Uterine cavity was visualized in its entirety including bilateral tubal ostia.  The endometrial lining was ***. Additionally, *** was noted.

***[Polyp forceps were inserted through the operating channel of the hysteroscope and the polyp was grasped and removed under direct visualization.] 

***[A gentle, sharp curettage of the cavity was completed.]  

All instruments were then removed from the vagina.  Pt was repositioned and extubated in stable condition.  Sponge, lap and instrument counts were correct x 2.

The cystoscope was advanced into the bladder. Initial inspection of the bladder showed increased vascularity but was otherwise normal in appearance. Both ureteral orifices with efflux. The bladder was distended with normal saline with approximately 250mL of fluid until fluid was leaking out the urethra around the cystoscope. Bladder was well distended with trabeculations noted. Pressure was placed under the urethra around the cystoscope to hold fluid in the bladder for hydrodistention lasting 8 minutes, and fluid was then drained. 

Patient was taken to the operating room with IV running. She was placed under general anesthesia. Pt was placed in dorsal lithotomy in candy cane stirrups and prepped and draped in the normal sterile fashion. A surgical pause was performed. Bladder was drained. A weighted speculum was inserted in the vagina. Cervix was multiparous in appearance and visually closed. A modified McDonald cerclage was performed using a ***[5mm Mersilene suture] ***[1 Prolene suture]. The anterior lip of the cervix was grasped with ring forceps. The suture was used to take circumferential bites through the body of the cervix close to the internal cervical os, starting at 12 o'clock and working around the cervix in a counterclockwise direction and ending in the 12 o'clock position. Suture was tied with a knot located at 12 o'clock. All instruments were removed from the vagina. Patient tolerated the procedure well and was taken to recovery in stable condition. Fetal heart tones were obtained by ultrasound both before and after surgery.

After cleansing the penis with chlorhexidine, a dorsal penile block was performed with 1 mL of 1% lidocaine.  Hemostats were then used to grasp the foreskin and a 3rd hemostat was used to break down the adhesions.  Hemostat was placed to make a dorsal slit and this was made with scissors.  The foreskin was retracted.  A ***1.3 cm Gomco clamp was fitted over the glans of the penis.  The clamp was situated in the excess foreskin and was removed with the scalpel.  The clamp was removed.  A sterile gauze was wrapped around the penis.  The area was hemostatic.