Operative Report Hysterectomy Question & Answer Guide (With Explanation)

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Original Question

Operative Report, Hysterectomy LOCATION: Inpatient, Hospital PATIENT: Charlotte Sweet ATTENDING PHYSICIAN: Andy Martinez, MD SURGEON: Andy Martinez, MD PREOPERATIVE DIAGNOSIS: Dysfunctional uterine bleeding POSTOPERATIVE DIAGNOSIS: Dysfunctional uterine bleeding PROCEDURE PERFORMED: Subtotal abdominal hysterectomy PREAMBLE:The patient is a 32-year-old gravida 4, para (to bring forth) 3, SA 1 who presented with a history of irregular menstrual bleeding. The patient had tried oral contraceptive pills to see if this would cause any improvement in her menses, but no improvement was noted. Trial of Provera also failed to cause any improvement in the cycles. The patient stated that she was done with her childbearing, and she requested definitive therapy in the form of abdominal hysterectomy. The ovaries were to be conserved given the patient’s age. The patient did have prior surgeries, including repair of a bicornuate uterus, as well as two cesarean sections in the past. PROCEDURE NOTE:The patient was taken to the operating room, and spinal anesthetic was administered. The patient was then prepped and draped in the usual manner in supine position. A Foley catheter was inserted. A Pfannenstiel incision was made through the pre-existing scar. There was lots of scarring of the fascia, and this was taken down sharply. The peritoneal cavity was then entered without incident. Upon inspection of the pelvis, the bladder was noted to be quite firmly adherent to the uterus anteriorly. Bicornuate shape of the uterus was noted. Both fallopian tubes and ovaries appeared normal to inspection. The uterus was grasped, and round ligaments were identified bilaterally. These were then suture ligated using 0 Vicryl. The anterior release of the broad ligament was then sharply entered to create the bladder flap. This was quite adherent mostly on the left-hand side. Bladder was then taken down away from the front of the cervix using sharp dissection. Again, the bladder was found to be quite densely adherent to the cervix, particularly on the left-hand side. Bleeding was encountered while trying to take the bladder down. At this point then, attention was directed toward the adnexa. Blunt finger dissection was used to create a hole in the broad ligaments to allow for placement of Heaney clamps bilaterally across the fallopian tubes and utero-ovarian ligaments. These pedicles were then cut and suture ligated with 0 Vicryl. Free tie was placed around each pedicle first so that these pedicles would be doubly ligated. At this point then, the uterine arteries were skeletonized bilaterally. Heaney clamps were then used to clamp the uterine arteries bilaterally, and pedicles were cut and suture ligated with 0 Vicryl. At this point, the cervix was palpated, and it was quite long and deep into the pelvis. Since the bladder was so adherent anteriorly given the patient’s previous surgeries, the decision was made just to complete a subtotal hysterectomy and leave the cervix in place to minimize patient morbidity. The fundus of the uterus was therefore sharply excised. The remaining cervical stump was then grasped using Kochers. Any remaining endometrium was cauterized at the level of the cervix. The cervical stump was then oversewn using 0 Vicryl. Good hemostasis was ensured. At this point, the pelvis was washed with sterile water. Bleeding site was identified on the right utero-ovarian pedicle, and this was suture ligated with 0 Vicryl. Good hemostasis was then ensured aside from a small amount of oozing, which persisted from the bladder. A small piece of Surgicel was therefore placed at the level of the bladder flap for this. The packs and retractors were then removed. The fascia was closed using running 0 Vicryl. The skin was then reapproximated using staples. The patient tolerated the procedure well and went to the recovery room in good condition. There were no complications. The estimated blood loss was 250 cc. Pathology Report Later Indicated: See Report 11- 4B. SERVICE CODE(S): ICD-10-CM DX CODE(S):

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