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PREOPERATIVE DIAGNOSIS: Desires permanent sterilization.

POSTOPERATIVE DIAGNOSIS: Desires permanent sterilization.

PROCEDURE PERFORMED: Laparoscopic bilateral tubal occlusion with Hulka clips.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 20 cc.

COMPLICATIONS: None.

FINDINGS: On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size. There were no adnexal masses appreciated. The vulva and perineum appeared normal. Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally. There was a functional cyst on the left ovary. There was filmy adhesion in the left pelvic sidewall. There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac. The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis. The liver was visualized and appeared normal. The spleen was also visualized.

INDICATIONS: This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization. She recently had a spontaneous vaginal delivery in June and her family planning is complete.

PROCEDURE IN DETAIL: After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia. She was then prepped and draped and placed in the dorsal lithotomy position. A bimanual exam was performed and the above findings were noted. Prior to beginning the procedure, her bladder was drained with a red Robinson catheter. A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum. The cervix was dilated so that the uterine elevator could be placed. Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made. The Veress needle was then inserted and using sterile saline ______ the pelvic cavity. The abdomen was then insufflated with appropriate volume and flow of CO2. The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope. A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty. Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube. A second Hulka clip was then placed across the entire diameter just proximal to this. There was good hemostasis at the fallopian tube. The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle. A second Hulka clip was placed just distal to this again across the entire diameter. Good hemostasis was obtained. At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic. The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed. The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl. The suprapubic incision was then closed with Steri-Strips. The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic. The patient tolerated that procedure well. The sponge, lap, and needle counts were correct x2. She will follow up postoperatively for followup care.

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