OPERATIVE NOTE CONTENT

VAGINAL HYSTERECTOMY AND ADD-ONS

[MORCELLATION]

[BSO]

[SALPINGECTOMY]

[MCCALL’S CULDOPLASTY]

[HIGH UTEROSACRAL COLPOPEXY...PART 1]

[ANTERIOR COLPORRHAPHY]

[POSTERIOR COLPORRHAPHY]

[HALBAN PROCEDURE]

[HIGH UTEROSACRAL COLPOPEXY...PART 2]

[TOT...PART 1]

[CYSTOSCOPY]

[TOT...PART 2]

[PERINEORRHAPHY]

SPONTANEOUS VAGINAL DELIVERY

INITIAL ABDOMINAL ENTRY

[JOEL-COHEN]

[PFANNENSTIEL]

[VERTICAL MIDLINE]

[MAYLARD]

[CHERNEY]

CESAREAN DELIVERY

ABDOMINAL HYSTERECTOMY

ABDOMINAL MYOMECTOMY

INITIAL LAPAROSCOPIC ENTRY

[DIRECT ENTRY METHOD]

[VERESS NEEDLE METHOD]

[HASSON METHOD]

TOTAL LAPAROSCOPIC HYSTERECTOMY

LAPAROSCOPIC BILATERAL TUBAL LIGATION

LAPAROSCOPIC SALPINGECTOMY

POSTPARTUM TUBAL LIGATION

DILATION AND SUCTION CURETTAGE

COLD KNIFE CONIZATION

[ENDOCERVICAL CURETTAGE]

LEEP

HYSTEROSCOPY D&C

[POLYPECTOMY]

[NOVASURE ABLATION]

ESSURE

OPERATIVE NOTE CONTENT

Prior to describing your procedure, you will need to list the following:

Your name and identifying number

Patient’s name

Date of service

Preoperative diagnosis

Postoperative diagnosis

Procedures performed

Primary surgeon

Assisting surgeon

Supervising staff

Anesthesia type

Estimated blood loss

Inputs (crystalloid/colloid/blood products)

Outputs (urine/other)

Operative findings

Specimens sent to pathology

Complications

Postoperative patient condition

Indications for procedure

VAGINAL HYSTERECTOMY AND ADD-ONS

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 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. The vesicouterine space was entered after elevating the vaginal mucosa with an Allis clamp and the Deaver retractor was placed in this space.

The cardinal ligaments were then clamped, sealed, and transected with the Ligasure device, incorporating the uterine vessels, 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.

[MORCELLATION]

Due to the size to the uterus, morcellation was performed. Tenacula were placed on either side of the cervix and the cervix was bivalved. Serial wedge resections were performed to debulk the uterus. Individual fibroids were identified and removed. Once the specimen, was adequately debulked, the normal hysterectomy technique was resumed.

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

The utero-ovarian ligaments were identified and clamped bilaterally after delivering the fundus of the uterus. These were sealed and transected with the Ligasure with hemostasis ensured at each pedicle.The uterus was then restored into its normal position and the remaining portion of the broad ligaments were sealed and transected, freeing the specimen. The specimen was then sent to pathology.

[BSO]

The right ovary was grasped with a Babcock clamp and the tube with an Allis clamp. The Ligasure 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.

[SALPINGECTOMY]

The right fallopian tube was grasped at the proximal end with an Allis clamp and a the distal end with another clamp. The Ligasure device was then used to to clamp, seal and transect the mesosalpinx until the fallopian tube was removed. Hemostasis was ensured.

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.

[MCCALL’S CULDOPLASTY]

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.

[HIGH UTEROSACRAL COLPOPEXY...PART 1]

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.

[ANTERIOR COLPORRHAPHY]

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 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.

[POSTERIOR COLPORRHAPHY]

A posterior repair was performed next. An incision was made across the introitus. Metzenbaum scissors were used to tunnel beneath posterior vaginal mucosa until the apex of the rectocele bulge was reached. At this point, the rectum was separated from the posterior vaginal mucosa using sharp and blunt dissection, and the rectal bulge imbricated in the midline with interrupted sutures of 2-0 vicryl suture. Levator ani muscles on either side were approximated in the midline with interrupted 0 Vicryl sutures. Excess posterior vaginal mucosa was excised, and the vaginal episiotomy was repaired by approximating the posterior vaginal mucosa with a suture of Vicryl #0.

[HALBAN PROCEDURE]

Due to excess tissue in the posterior cul-de-sac, a modified Halban procedure was performed. A suture of 2-0 vicryl was used to obliterate the peritoneum of the posterior cul-de-sac in three rows. The posterior cuff was attached to the most superior row of sutures.

[HIGH UTEROSACRAL COLPOPEXY...PART 2]

The previously retained prolene sutures from the uterosacral colpopexy were then connected to the anterior and posterior vaginal walls on the contralateral 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.

[TOT...PART 1]

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 foramina on either side. The Obtryx curved device was then deployed per manufacturer’s direction on either side.

[CYSTOSCOPY]

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.

[TOT...PART 2]

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 bladder was drained.

[PERINEORRHAPHY]

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.

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.

SPONTANEOUS VAGINAL DELIVERY

The patient is a _ year old G_P_ admitted at ___weeks gestation [in active labor]. [Brief description of labor course].

She was noted to be complete and began to push. She went on to deliver a vigorous [fe]male 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 2nd degree midline laceration which was repaired with a 2-0 monocryl 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.

INITIAL ABDOMINAL ENTRY

[JOEL-COHEN]

A straight, transverse 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.

[PFANNENSTIEL]

A curvilinear low transverse incision was made across the abdomen, centered 2 centimeters above the symphysis pubis and extending approximately 12 cm from end to end. The incision was carried down sharply to the fascia, which was sharply incised and extended with sharp and blunt dissection. The anterior rectus sheath was dissected off of the rectus muscles superiorly and inferiorly. The peritoneum was entered bluntly in a cephalad direction between the rectus muscles, and laterally extended.

[VERTICAL MIDLINE]

A linear incision was made in the midline, extending from 2cm superior to the symphisis pubis to 1cm inferior to the umbilicus. This was extended in a curved fashion around the left side of the umbilicus with approximately 1cm margin. The incision was carried down sharply to the fascia, which was sharply incised and extended with sharp dissection. The rectus abdominis muscles were retracted laterally.

[MAYLARD]

A curvilinear low transverse incision was made across the abdomen, centered at the level of the anterior superior iliac spines and extending approximately 15 cm from end to end. The incision was carried down sharply to the fascia, which was sharply incised and extended with sharp and blunt dissection. The deep inferior epigastric arteries on each side were identified at the lateral borders of the rectus muscles. These were doubly ligated and transected. Each rectus muscle was elevated with a retractor and transected with electrocautery. Finally, the transversalis fascia and peritoneum were dissected transversely.

[CHERNEY]

CESAREAN DELIVERY

After appropriate consent was obtained, the patient was taken to the operating room where adequate regional anesthesia was ensured and she was placed in supine position. She received appropriate antibiotics on call to the operating. 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.

[INITIAL ABDOMINAL ENTRY]

A low transverse incision was made across the uterus. 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 umbilical cord was clamped and cut and infant was handed to pediatric team.

A bladder blade was inserted and the lower uterine segment visualized. An incision was made transversely in the lower uterine segment. The entry into the uterus was made bluntly and the hysterotomy was extended superiorly and inferiorly in a blunt fashion.

[BREECH PRESENTATION]

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.

[CEPHALIC PRESENTATION]

The fetal head was cupped at the occiput and flexed and then delivered atraumatically with fundal pressure. Afterwards, the rest of the body followed easily and atraumatically.

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.

[MODIFIED PARKLAND TUBAL LIGATION]

Attention was then turned to the tubal ligation. The right tube was identified and grasped with a Babcock clamp and then the mesosalpinx was entered in with Metzenbaum scissors and a window made in the avascular portion of the mesosalpinx. Plain gut suture was used to ligate the proximal and distal portions of the tube, which was then excised. Hemostasis was noted. The procedure was repeated on the left side. The two tubal segments were sent to Pathology.

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 x 2.

ABDOMINAL HYSTERECTOMY

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.

[INITIAL ABDOMINAL ENTRY]

A(n) [O’Connor-O’Sullivan, Alexis-O retractor, Bookwalter, etc.] 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 round ligaments on both sides were clamped, transected, and suture ligated with 0-Vicryl [or with the Ligasure, etc.]. 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 infundibulopelvic ligaments on both sides were doubly clamped, transected and suture ligated with 0-Vicryl/ Ligasure.) The uterine arteries were skeletonized bilaterally, clamped, transected and suture ligated with 0-Vicryl [or Ligasure, etc.]. 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 [cautery, 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 series of interrupted 0-Vicryl figure-of-eight sutures, a running stitch of Monocryl, etc.]. Hemostasis was ensured.

The pelvis was irrigated with warm water. All laparotomy sponges and instruments were removed from the abdomen. (The peritoneum was reapproximated with 4-0 chromic). 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.

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.

ABDOMINAL MYOMECTOMY

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.

[INITIAL ABDOMINAL ENTRY]

An Alexis-O self-retaining retractor was placed into the incision. The uterus was palpated and the fibroid identified. It was injected with vasopressin, 20 units mixed in 30 ml of normal saline along the serosal surface, taking care to aspirate in order to avoid any blood vessels. 15 ml total was injected.

Cautery was used to cut a linear incision along the top of the fibroid until fibroid fibers were seen. The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to dissect around the fibroid followed by blunt dissection with a finger. The fibroid was easily and bluntly dissected out. It was grasped with Lahey clamp to apply traction until it was completely enucleated.

Several smaller fibroids were removed in similar fashion.

Next, the uterine incision was closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch. The uterus was seen to be hemostatic after closure.

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 suture. The skin was closed with 4-0 monocryl in a subcuticular fashion. Dermabond was placed along the length of the incision.

The procedure was deemed complete. An RF scan was done and was negative. Sponge, needle, and instrument counts were correct. The patient was awakened from anesthesia and taken to the recovery room in stable condition.  

INITIAL LAPAROSCOPIC ENTRY

[DIRECT ENTRY METHOD]

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.

[VERESS NEEDLE METHOD]

Two towel clamps were placed approximately 1cm laterally at both sides of the umbilicus and everted. A 5 mm skin incision was made within the umbilical fold. Upward traction was applied with the towel clamps. High-flow CO2 gas was connected to the Veress needle, which was advanced through the incision. Intraperitoneal location was confirmed by noting a drop in gas flow pressure. Insufflation was continued to 15 mmHg. The Veress needle was removed and the 5mm laparoscopic camera and trocar were inserted into the incision. Intraperitoneal access was confirmed by direct visualisation, and no signs of needle or trocar injury to the omentum or bowel were noted.

[HASSON METHOD]

The inferior edge of the umbilicus was elevated with Allis clamps and an approximately 1 cm incision was made. The fascia was grasped with a pair of Kocher clamps after dissection and incised. The peritoneum was entered with Metzenbaum scissors after elevation and inspection. A digital sweep was made to ensure no adhesions around the opening and the trocar was placed with and the balloon inflated. (Alternately: the fascia was tagged with two stay sutures and the trocar was placed and secured with the stay sutures).

TOTAL LAPAROSCOPIC HYSTERECTOMY

The patient received 1g Ancef IV (and 100mg pyridium) 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 (RUMI / ZUMI / Vcare / other) uterine manipulator was placed.

[INITIAL LAPAROSCOPIC ENTRY]

An intra-abdominal survey revealed the findings as previously noted. Two 5 mm (or 8 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.

[If BSO - The IP ligament was clamped, sealed, and divided, hugging the ovary as much as possible].

[If no BSO - 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 (/Fallopian tubes/ovaries) were removed through the vagina. The vaginal cuff was closed with Vicryl suture in a continuous running fashion from the vaginal approach (or with barbed or Vicryl suture laparoscopically). The uterosacral ligaments were incorporated into the closure.

[CYSTOSCOPY IF INDICATED]

The pelvis was irrigated and hemostasis confirmed at decreased insufflation pressure. All instruments were removed from the abdomen. Skin incisions were closed with Dermabond (/subcuticular suture/steri-strips). Sponge, needle, and instrument counts were correct. The patient was returned to supine position, awakened, and transferred to recovery in stable condition.

LAPAROSCOPIC BILATERAL TUBAL LIGATION

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.

[If no manipulator - A sponge stick was placed in the vagina under the cervix.]

[If a manipulator is desired - A bivalve speculum was then placed into the vagina and the anterior lip of the cervix was grasped with a single-toothed tenaculum. The cervix was then sequentially dilated to accommodate the manipulator and a [HUMI, Hulka, etc.] was then advanced into the uterus to provide a means to manipulate the uterus. The speculum was then removed from the vagina.]

[INITIAL LAPAROSCOPIC ENTRY]

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 positon 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 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.

LAPAROSCOPIC SALPINGECTOMY

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.

[If no manipulator - A sponge stick was placed in the vagina under the cervix.]

[If a manipulator is desired - A bivalve speculum was then placed into the vagina and the anterior lip of the cervix was grasped with a single-toothed tenaculum. The cervix was then sequentially dilated to accommodate the manipulator and a [HUMI, Hulka, etc.] was then advanced into the uterus to provide a means to manipulate the uterus. The speculum was then removed from the vagina.]

[INITIAL LAPAROSCOPIC ENTRY]

Immediate inspection of the abdominal cavity revealed [normal pelvic anatomy / blood in the posterior cul-de-sac with a bleeding tubal pregnancy on the left/right side / a hydrosalpinx on the left/right side.

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 Ligasure 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.

[If bilateral salpingectomy is indicated - 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.

POSTPARTUM TUBAL LIGATION

The patient was taken to the operating room where [her epidural was bolused and found to be adequate / a spinal anesthetic was placed without difficulty / general endotracheal anesthesia was obtained]. 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 an 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 in 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.

DILATION AND SUCTION CURETTAGE

The patient was taken to the operating room where she underwent general endotracheal anesthesia without difficulty . She was placed in a dorsal lithotomy position in candy cane stirrups. A surgical pause was then performed.

A bivalve speculum was placed in the vagina to gain visualization of the cervix which was cleansed with a betadine solution. The anterior lip of the cervix was grasped with a tenaculum. The cervix was then serially dilated to ___mm and a ___ mm curved suction cannula was inserted. Suction was applied and serial passes with the suction curette were performed with gestational products removed. A pass with a dull metal curette was performed with one additional pass with the suction curette. All instruments were removed. There was no significant bleeding from the cervix. Examination of the tissue was consistent with the gestational age. Sponge, lap, needle, and instrument counts were correct X2. The patient was repositioned, extubated and transported to recovery room in stable condition.

The patient received Doxycycline in holding prior to the procedure. [The patient received Rhogam prior to discharge due to Rh- blood type.]

COLD KNIFE CONIZATION

The patient was taken to the operating room where she underwent general anesthesia without difficulty. The patient was placed in the dorsal lithotomy position in candy cane stirrups. The patient was then prepped and draped in the usual sterile fashion. A surgical pause was conducted.

A weight retractor and a curved Deaver retractor were used to gain exposure to the cervix. #0 Vicryl sutures were placed into the cervicovaginal junction at the 3 o’clock and 9 o’clock positions for hemostasis and manipulation of the cervix.

A circumferential incision about 2 cm in diameter, centered over the external os, was then performed with the scalpel. This central tissue was grasped and the scalpel was then used to make a cone approximately 2cm in length, with the apex centered over the endocervical canal. The cone was marked at 12 o’clock with a suture and sent to pathology.

[ENDOCERVICAL CURETTAGE]

A Kervorkian curette was used to obtain an endocervical specimen.

The cone bed was inspected for bleeding which was controlled with electrocautery. Monsel’s solution was applied to obtain excellent hemostasis. All instruments were removed and the patient was repositioned to the supine position. Sponge, lap, needle, and instrument counts were correct x 2. She was awaked and taken to the recovery room in stable condition.

LEEP

The patient was taken to the operating room [where she received sedation]. The patient was placed in the dorsal lithotomy position in candy cane stirrups. A grounding pad was applied to her thigh. The patient was then prepped and draped in the usual sterile fashion. A surgical pause was conducted.

An insulated speculum was inserted and smoke evacuator was attached. The cervix was circumferentially injected with __ ml of lidocaine 1%  [with epinephrine 1:100,000]. The generator settings were checked and found to be appropriate. Electrosurgical conization using a __ mm cone excisor was performed. The specimen was sent to pathology.

The cone bed was inspected for bleeding which was controlled with electrocautery. Monsel’s solution was applied to obtain excellent hemostasis. All instruments were removed and the patient was repositioned to the supine position. Sponge, lap, needle, and instrument counts were correct x 2. She was awaked and taken to the recovery room in stable condition.

HYSTEROSCOPY D&C

The patient was taken to the operating room where she underwent general endotracheal anesthesia without difficulty . She was placed in a dorsal lithotomy position in candy cane stirrups and prepped and draped in the normal manner. A surgical pause was then performed.

A bivalve speculum was placed in the vagina to gain visualization of the cervix. The anterior lip of the cervix was grasped with a tenaculum. The cervix was then serially dilated to 6 mm and a hysteroscope was placed with water running. The cavity was visualized, including both tubal ostia, with the findings noted above. The hysteroscopy was removed.

[POLYPECTOMY]

The polyp forceps were used to grasp the previously visualized polyp over two or three passes. Tissue consistent with the visualized polyp was removed.

A sharp curette was used to scrape the cavity systematically until a gritty texture was felt. A moderate amount of tissue was obtained and sent to Pathology.

[NOVASURE ABLATION]

The uterus was sounded to be __ cm with a cervical length of __ cm for a total cavity length of __ cm.  The NovaSure device was then introduced inside the uterus and deployed per manufacturer’s instructions. The uterine width was assessed to be __ cm. The cervical collar was advanced. The cavity assessment was completed. The system was then activated for __ seconds at __ watts. At the end of the cycle, the NovaSure was removed.

All instruments were removed. There was no significant bleeding from the cervix. Sponge, lap, needle, and instrument counts were correct X2. The patient was repositioned, extubated and transported to recovery room in stable condition.

ESSURE

Patient was counseled regarding the risks/benefits/alternatives/permanence of the Essure hysteroscopic sterilization technique. She was counseled regarding the need for an HSG in 3-6 months and the need for back-up contraception until tubal occlusion has been confirmed. Consent was obtained for the procedure and all questions answered.

The patient was taken to the operating room, She was placed in a dorsal lithotomy position in stirrups and prepped and draped in the normal manner. A surgical pause was then performed.

The patient took Vicodin 5-10 mg and Valium 5-10 mg orally prior to presenting. She received an IM injection of 60 mg of Ketorolac mixed with 0.4 mg of atropine at presentation. UPT was negative.

A speculum was placed and the cervix grasped. 2-3 ml of Mepivicaine 1% was injected in the cervical stroma at 12 o’clock. A sterile single-toothed tenaculum was used to grasp the anterior lip of the cervix. 5-10 ml of Mepivicaine 1% was injected at 3, 6, and 9 o’clock approximately 1 cm deep at the fornix. 5-10 ml of Mepivicaine 1% was then injected at 5:30 and 7:30 o’clock with a depth of 2 cm in the cervical stroma. Hemostasis was ensured.

[The above section is removed if general anesthesia is used]

The cervix was dilated to approximately 5 mm. The hysteroscope was placed and the uterine cavity inspected. Both tubal ostia were identified. The Essure device was inserted and the spring placed in the left and then another spring in the right tube according to the manufacturer’s instructions.

There were __ coils present in the left side and __ coils present on the right side.

The hysteroscope was removed and the tenaculum removed. Hemostasis was ensured. The patient was taken to recovery.

The patient was instructed to use alternate birth control until the confirmation test in 3 months.