Medical Specialty:
Obstetrics / Gynecology
Sample Name: TAH & Salpingo-oophorectomy
Description: Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy. Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES:
1. Hypermenorrhea.
2. Uterine fibroids.
3. Pelvic pain.
4. Left adnexal mass.
5. Pelvic adhesions.
POSTOPERATIVE DIAGNOSES:
1. Hypermenorrhea.
2. Uterine fibroids.
4. Left adnexal mass.
5. Pelvic adhesions.
PROCEDURE PERFORMED:
1. Total abdominal hysterectomy (TAH).
2. Left salpingo-oophorectomy.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 100 cc.
INDICATIONS: The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003. The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.
FINDINGS AT THE TIME OF SURGERY: Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.
On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass. The bowel, omentum, and appendix had a normal appearance.
They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture. The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps. These were then transected and suture ligated with #0 Vicryl suture. The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible. It was then entered with the last transection. The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors. The angles of the vaginal cuff were then grasped with Kocher clamps. A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed. Good hemostasis was appreciated. A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl. This was tagged for later use. The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture. The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place. The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated. The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion. The GYN/Balfour retractor and bladder blade were then removed. The bowel was then packed. Again copious suction irrigation was performed with hemostasis appreciated. The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion. The fascia was then reapproximated with #0 Vicryl suture in a running fashion. The Scarpa's fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion. Steri-Strips were placed. At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally. The patient tolerated the procedure well and was taken to Recovery in stable condition. Sponge, lap, and needle counts were correct x2. Specimens include uterus, cervix, left fallopian tube, and ovary.
Keywords: obstetrics / gynecology, hypermenorrhea, pelvic adhesions, pelvic pain, adnexal mass, tah, total abdominal hysterectomy, uterine fibroids, salpingo-oophorectomy, vicryl suture, kocher clamps, vaginal cuff, vicryl, suture, abdominal, uterus, vaginal, uterine, pelvic, adnexal, ligament,