Thanks for your help, BigRed.
Here is the op report:
POSTPROCEDURE DIAGNOSIS: Clinical severe adenomyosis, normal ovaries and tubes with corpus luteum on the right side, hypermobile urethra, deep cul-de-sac with apical mild descent, no active endometriosis, IUD was removed.
PROCEDURE PEFORMED: Laparoscopy, supracervical abdominal hysterectomy, high ureterosacral ligament vault suspension bilaterally, and washing and transobturator tape/Monarch suburethral sling.
Following the prep, Foley catheter was inserted sterilely, as was the bivalve speculum followed by tenaculum grasping the anterior cervical lip, and Valtchev attached. Speculum removed, over-gloves changed. 10mL 0.25% Marcaine with epinephrine was injected infraumbilically. Three attempts to insert the Veress needle without success. She had previous laparoscopies; therefore, concern about adhesive disease. It was decided at this point to approach it with a left upper abdomen, about midclavicular line, about 3 cm below the lowest costal margin. A 5-mL injected stab incision made, a Veress needle introduced, This was a negative aspiration, free-flowing saline, but the opening pressure was 12. Therefore, this was abandoned as well. At that point decision was to do an open. Infraumbilical incision was extended to 4 cm. Subcutaneius tissues separated, fascia identified, elevated, incised, and the fascia once incised and extended to about 3 cm, the rectus muscles were separated in the midline. Preperitoneal fat was separated. Peritoneum was identified, elevated, and incised. Once this was done, peritoneum and fascia on either were secured together with a single interrupted stitch of 0 Vicryl and tagged.
Hasson atraumatic sleeve and trocar were introduced. The sleeve was held in place by tying to the Vicryl sutures, and trocar removed. Scope replaced. Abdomen was insufflated confirming intraabdominal placement without evidence of adhesive disease. Two lateral ports 10 mm were inserted lateral to the epigastric vessel, what appeared to be under transillumination as well as intraabdominal visualization, first on the left side. 10 mL of 0.25% Marcaine was injected and incision was made and trocar introduced. With this in place, then attention was directed toward the right side, in the same manner was attached, inserted. Suprapubic 5 mm port was carried out after injecting 5 mL 0.25% Marcaine, a stab incision made followed by 5 mm trocar.
Just prior to initiating hysterectomy, washings were obtained, aspirated, and sent to pathology. During that time it was noted dripping of blood from the right lateral port; and beginning about 3 cm above the trocar, hematoma was developing. At that point using Carter-Thomason needle for closing the fascia using Vicryl, a stab incision was made lateral on both sides superior to the trocar sleeve; and Vicryl was introduced, passed from one side to the other and brought out. This was tied onto by putting a gauze 4x4 between the skin and suture knot. This compressed hematoma and no active bleeding was noted.
Proceeded with hysterectomy in the following manner: Using LigaSure approaching both by pushing the uterus, anteverting it, midline and to the right, the cornu at the tube was desiccated and transected followed by uteroovarian ligament x2 bites followed by the round ligament. Then bites of 2 cm each taking onto the lower uterine segment. Then attention was directed toward the patient's right side by pulling the uterus superior and towards the left. In the same manner, the uteroovarian ligament, tube, round ligament, and broad ligament underneath the round ligament was desiccated, transected with LigaSure with 2 bites down to the lower uterine segment; and using laparoscopic scissors, the vesicoperitoneum was separated from the lower uterine segment and adventitial tissue separated and taken down, exposing the entire anterior cervix. The uterine artery on either side was clamped with LigaSure, desiccated and transected, 2 bites, followed by the venous plexus below.
There was still some bleeding, especially on the left side where we could see retrograde bleeding. But it was much more arterial, and there was concern about intracervical or just under the surface of the lower uterine segment cervix there would be an arterial. This was found, clamped, desiccated and transected. Once this was done, the uterus became ashen, and no active bleeding was noted.
Once this was done, then using electrocautery at 30 watts hook-tip cautery, transection by grasping the lower uterine segment above the cut with a tenaculum, and circumferential incision was used, monopolar cautery tip coning towards ectocervix. Once the Valtchev was exposed, the circumferentially the uterus body was detached. There was a deep cone of about 2.5 cm, thus leaving about a half a centimeter of the endocervical canal in the distal portion. This area was coagulated as well.
Then the left lateral port was removed, the morcellator was introduced. The uterus was morcellated and small fragments were removed. No active bleeding was noted. Irrigation of the surgical field with saline, reaspirating back, confirming hemostasis throughout.
At that point it was decided the uterosacral ligament about 3.5 cm proximal to it insertion to the cervix on the right side could be found to be thick and bulky with a ureter passing about a centimeter lateral to it. This portion was grasped with a laparoscopic Allis, and 0 Ethibond suture was used through and through and then running in and out distally through the attenuated portion of the uterosacral ligament until its insertion to the cervix, and was brought into the cervix and out again and these tied down, shortening and elevating the cervix and the vaginal vault on the right side. In the same manner, the left side was accomplished as well, avoiding the ureter.
Once this was done, the deep cul-de-sac was closed by placing the cervix and upper vagina in a normal anatomical position. Then the cervical stump, because there were Ethibond sutures, the cervical stump wa closed with interrupted box stitches of 0 Vicryl as well. Once this was done, irrigation of pelvis with copious saline, removed. No active bleeding. Bilateral peristaltic ureters were visualized. Urine was clear.
At that point the left lateral port was removed, replaced with Carter-Thomason. A #0 Vicryl was used to suture the peritoneal fascia but without tying it. The sleeve was reintroduced. Then on the right side, the 10mm trocar was removed and replaced with Carter-Thomason, but this time the ____Vicryl was placed to control the distal superficial epigastric that was lacerated through the insertion of the port, as well as closing the fascia. Once those stitches were placed, they were tied, both of them, and distally bleeding stopped as well. Superiorly the hematoma remained stable, about 2 cm, and no active bleeding was noted.
The left lateral port was closed, and the umbilical port was removed. CO2 was allowed to escape, as well as the suprapubic port. The fascia and peritoneum, previously tagged with 0 Vicryl was used to run side-to-side the lower portion from 1 suture on the right in the upper portion from the suture using on the left side. These were closed. Subcutaneous fat was reapproximated with 3 interrupted stitches of 0 Vicryl. Skin was closed with 4-0 absorbable suture of Monocryl, umbilicus, and 2 lateral ports, and suprapubically. Band-Aids were placed and gause was placed on top of the retention suture and covered. This will be removed tomorrow morning.
The abdomen was cleansed and Trendelenburg was reversed. Then attention was directed to the perineum. By flexing the hips and knees to 90 degrees, lateral incisions for the TOT were palpated intravaginally and transperineally finding the medial lower portion obturator foramen on both sides at the level of about a centimeter below the clitoris. These markings were placed. 0.5mL of 0.25% Marcaine was injected intradermal and subdermal, and then 10 mL deposited all the way to the obturator foramen, both internal and external sheath. The same thing was done on the opposite side. Suburethrally was identified midurethral by palpating the Foley and its balloon in the bladder. This was grasped with Allis's. 2 mL of 0.25% marcaine was injected suburethrally, and then 10 mL on either side to underneath the pubic rami. A small incision about a centimeter and a half was made suburethrally. Edges of the vaginal mucosa were grasped with Allis and sharp dissection with Metzenbaum under the vaginal skin toward the fornices. It was accomplished and then obturator foramen spiral trocal was introduced on patient's left side first, perforating the membrane x2 and then rotating the wrist with the surgeons' opposite hand in the vaginal fornix to guide to the mid-urethra subdermal region to expose it easily; and the contralateral side was performed using the opposite hand in the same manner. Once these were placed, a hammock sling with a sleeve was soaked in saline, was attached appropriately. Yankauer suction tube without its tip was placed suburethrally, and once the sling was attached to the trocar, each one was withdrawn without tensioning to the Yankauer cathereter. The excess mesh and the sleeve was detached from the trocar on both sides, and then the sleeve was grasped with hemostats on both sides, simultaneous constant traction, removing the sleeve, covering the middle ear space, and the mesh laid flat against the Yankauer loosely. Excess mesh was trimmed off in the perineum.
Then the Yankauer was removed, laying flat against the midurethral without tension, and the vaginal mucosa was closed with 2 interrupted stitches of 4-0 Vicryl. Then retropubic digital compression was carried out for 5 minutes. Once this was done, the perineal skin was reapproximated with Dermabond and Steri-Strips. The perineum was cleansed. The patient's anesthesia was reversed, she was transferred, left the operating room in satisfactory condition.
