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Posted By Maria on 03-08-2018, 16:38:28 in Ob-Gyn
Hey Melanie,


I am thinking this is a TLH .

1) All connections are detached laparoscopically. TLH

2) A posterior colpotomy was made circumferentially freeing up the specimen, which was brought out through the vagina. TLH

3) The closing of the vaginal cuff. It is not clear to me that he is closing laparoscopic or not.

The Dr immediately states after the closing the cuff that "The pelvis was then irrigated and the vaginal cuff was noted to be hemostatic. The infundibulopelvic ligaments were noted to be hemostatic as well. The instruments were then removed and the robot was undocked. "

This is leading me to believe that he is using the laparoscope to irrigate the pelvis and to be able to view the infundibulopelvic ligaments.

Am I missing something there in my assuming.?

Do I need to ask Dr to be more specific that he sewed the cuff using the laparoscope?

Or is this something that is a given in the way he has written the report that is indicating that, without really saying it?


The report is below.

After assuring informed consent the patient was taken back to the operating suite and induction of general anesthesia was done. The patient was placed in the modified dorsal lithotomy position in Allen stirrups then prepped and draped in the normal sterile fashion. The weighed speculum was placed in the patient’s vagina and the cervix was grasped at the 12 O’clock position with a single tooth tenaculum. The uterus was sounded to 8 cm and the cervix was dilated with the hank dilators up to a number 15. A medium V-Care uterine manipulator was placed inside the uterine cavity. Foley catheter was placed. Gloves were changed and attention was then taken to the abdomen.
 
A supraumbilical skin incision was then made approximately 22 cm above the pubic symphysis and a veress needle was introduced into this incision. Once proper placement was noted by physical examination and sterile water flowing easily into this incision then CO2 gas was insufflated into the abdomen at a maximum pressure of 15 mmHg. A 10/12 blunt trocar was then inserted through this incision and the Robotic camera verified proper placement of this port. Bilateral blunt robotic trocars were then placed 10 cm lateral and 15 degrees inferior lateral from the midline camera port. An additional left flank robotic port was placed 10 cm lateral and 15 degrees upward from the prior robotic port. A 10/12 accessory port was placed beneath the right costal margin. The patient was then placed in steep trendelenberg position and the robot was docked. The monopolar scissors were placed in the right robotic arm; bipolar fenestrated graspers in the left robotic arm and the double fenestrated graspers were placed in the third robotic arm.
 
Bilateral round ligaments were taken down with monopolar cautery and the retroperitoneal space was opened. The underlying ureters were visualized and the infundibulopelvic ligaments bilaterally were cauterized with bipolar cautery and cut with monopolar cautery. The vesicouterine peritoneum was incised and the bladder was dissected off the lower uterine segment and cervix. The uterine vessels were then cauterized bilaterally with the bipolar and transected with the monopolar cautery. The cardinal and uterosacral ligaments were then cauterized with the bipolar and transected with the monopolar cautery. A posterior colpotomy was made at the level of the Vcare and brought around circumferentially freeing up the specimen, which was brought out through the vagina.
 
The vaginal cuff was then reapproximated with 0 PDS in a running fashion, starting from either end and tying in the middle. The pelvis was then irrigated and the vaginal cuff was noted to be hemostatic. The infundibulopelvic ligaments were noted to be hemostatic as well. The instruments were then removed and the robot was undocked. The pneumoperitoneum was then evacuated and all trocars were removed. The 12 mm trocar fascia sites were reapproximated with a figure of eight stitch of 0 vicryl. All skin incisions were closed with a 4-0 vicryl subcuticular stitch. Steri-strips were placed as well as bandages. The vagina was examined with sponge sticks x 2 and noted to be hemostatic. Sponge, lap, needle and instrument counts were correct x 2. The patient was taken to the recovery room in awake and stable condition.
Comments (1)
Posted By Melanie Witt on 03-10-2018, 15:24:55
This sounds to me like he closed the vaginal cuff via the laparoscope from above.
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