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58571 – 57288
N81.2, N83.201
Dx: N39.3

Surgery: 04/02/2018

Surgeon: X.X. XXXXXXX, M.D.
XXXX. X surgical assistant.
Third year medical student in attendance.

Preoperative diagnoses: Prolapsed uterus and stress incontinence.
Postoperative diagnoses: Same and patient had a right large ovarian cyst.
Anesthesia: General

Description of procedure: We had a time-out identified the patient’s name and date of birth. She was given antibiotics. The patient had no major risk factors. Complications were none. Estimated blood loss was 50 mL. Preoparative1y, she had gabapentin, Tylenol as well as Lyrica as part of the protocol to cut down her opioid use after surgery. She was also given Toradol intraoperatively and then we gave her On-Q pain pump for pain.

This is a 46-year-old black female. She had prolapsed uterus causing her pressure, but she also had 2 previous bladder repair procedures that we removed the mesh, removed the suture, gave her proper time of healing, give her Estring cream for re-estrogenizing the vagina, and then we decided to go ahead and repair this. So, the patient was prepped and draped in the usual manner. Observing all aseptic technique, she was given a general anesthetic and prepped and draped. We put in a uterine manipulator and a Foley catheter and then we turned our attention to the above. We put in 4 port sites. These port sites were docked to an X1 robot, 1 port was for the camera, 1 port was for the PK bipolar cautery and laparoscopic scissors of the port, and then we had an assist port. The patient was docked to the patient’s side-docking in a steep Trendelenburg position. Then, we turned our attention to the console.

After the patient was docked appropriately, we want on inspecting and saw a large right ovarian cyst that we thought would need to be removed. We looked at the left side. The left side was totally normal. So, we started on the left side at the round ligament. This was cauterized with the PK and then laparoscopically we cauterized and then developed an anterior and posterior aspect of the broad ligament. Then, we looked at the infundibulum and in the ovarian ligament. This was cauterized until secure, and then, laparoscopically we used scissors for cautery as well as to excise the tissue. We skeletonized and want down to the bladder flap anteriorly and went posteriorly and then we skeletonized and saw the uterine vessels they were cauterized until secure.

Then, we turned our attention to the right side, which was a large ovarian cyst. We took the right ovary by going through the infundibulopelvic pelvic 1igament, IP. This was cauterized and cut until secure and then we went up to the broad ligament inc1uding removing the fallopian tubes and then the round ligament. We excised anteriorly again to deve1op bladder flap posterior1y just to get down to the uterine vessels that were cauterized. Then, once they were cauterized and secure next our attention to pushing the bladder well off the cervix. By using the uterine manipulator, the caudal ligaments were secure and then we circumferentially removed the cervix and then we pulled it out the cervix.

The uterus and the right tube and ovary through the vagina, irrigated, and then we used the V-Loc running locked stitch to secure the cuff, running it forward and backwards for good hemostasis. AlloWrap was used to put on the cuff to prevent any adhesive disease, and then we put in a pain pump, On-Q pain pump for pain. This was put in without complications. Then, as my assistant was closing the port site and undocking the robot, I turned my attention to below.

At this point, the patient was still in the dorsal lithotomy position, 1.5 cm from the urethral meatus, we did do a vertical incision and removed that 1 stitch that was from a previous surgery and then undermined until we got to the operative fossa. This was done bilaterally and at the level just below the pubic ramus, but also below the obturator fossa and then we used the Co1oplast TOT, and we anchored it on one side to the left side first and then we made sure the sling was lying flat and at the center of the posterior urethrovesical angle and then the second right side was placed and without complications.

We secured it and tied it up with tension. Then, we cut the suture and then we reapproximated the incision with 0 and 3-0 Vicryl in a running locked stitch. We took out the catheter. There was no need for cystoscopy since we did not do a TVT or TOT. The urine was clear. There was no air into the Foley catheter. We discontinued the procedure. The patient was transferred to the PACU in satisfactory condition.