DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 36-4/7 weeks’ gestational age.
2. Spontaneous rupture of membranes.
3. Previous cesarean section x2.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 36-4/7 weeks’ gestational age.
2. Spontaneous rupture of membranes.
3. Previous cesarean section x2.
4. Severe adhesive disease.
SURGEON: John Doe, MD
PROCEDURE PERFORMED: Repeat low transverse cesarean section.
FINDINGS: Septate uterus with separated cornua and uterus markedly enlarged, also viable male infant with Apgars of 9 and 9, present within uterine cavity.
DRAINS: Foley to gravity.
ESTIMATED BLOOD LOSS: 1350 mL.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought in for repeat low transverse cesarean section. Spinal anesthesia was obtained to an appropriate level. The patient was then prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made and carried down sharply to the fascia. The fascia was incised and dissected superiorly to the level of the umbilicus and inferiorly to the pubic bone. The rectus muscles were separated in the midline using both blunt and sharp dissection along with Bovie cautery. There was marked adhesive disease in the midline, and there was a large amount of scar tissue that required dissection to separate the rectus muscles.
A Pfannenstiel skin incision was made and carried down sharply to the fascia. The fascia was incised and dissected superiorly to the level of the umbilicus and inferiorly to the pubic bone. The rectus muscles were separated in the midline using both blunt and sharp dissection along with Bovie cautery. There was marked adhesive disease in the midline, and there was a large amount of scar tissue that required dissection to separate the rectus muscles.
Once the abdominal cavity was reached, there was marked adhesive disease between the abdominal wall and the anterior surface of the uterus. These adhesions were dissected off the anterior surface of the uterus using sharp dissection using Metzenbaum scissors. A bladder flap was created by further dissecting the scar tissue away from the lower uterine segment, and a bladder blade was placed.
A low transverse incision was then made and a viable male infant with Apgars of 9 and 9 was delivered atraumatically. The mouth and nose suctioned. The cord was clamped and cut. The infant was handed to the awaiting pediatrician. The placenta was delivered manually after much effort and removed in pieces. The uterus was markedly enlarged, almost double the size of an ordinary post-delivery uterine size, with a septation by the cornua separating the cornua. The placenta straddled the septation extending into both cornua and had to be removed manually in pieces with much difficulty.
The uterus was unable to be exteriorized, and once the placental fragments were removed, the low transverse incision was reapproximated using 0 chromic in a running locking fashion. Several figure-of-eight 0 chromic sutures were then placed for hemostasis. The low transverse incision was found to be hemostatic and the paracolic gutters were then cleared of blood clots. The low transverse incision was then covered with
The low transverse incision was then covered with Surgicel to help provide additional hemostasis. The rectus muscles were then reapproximated in the midline using three 0 chromic figure-of-eight sutures. The fascia was then reapproximated using 0 Vicryl in a running locking fashion.
Before finishing closing the fascia, there was a large amount of pooling of what at first was thought to be rundown bleeding, and it was decided to re-enter the abdominal cavity to ensure hemostasis throughout, so the suture within the fascia and the rectus muscles were removed and the low transverse incision within the uterus reinspected and again found to be hemostatic, except for one edge where an additional 2-0 chromic figure-of-eight suture was placed, allowing for hemostasis.
All the other wound edges as well as the bladder flap and the paracolic gutters were reinspected and found to be hemostatic. The rectus muscles were reapproximated using 3 U stitches of 0 chromic. The fascia was then reapproximated using 0 Vicryl in a running, nonlocking fashion. The subcutaneous tissues were irrigated. Bovie cautery was used for hemostasis. Three 0 catgut interrupted sutures were placed in the subcutaneous fatty tissue. The skin was then closed with staples, and a pressure bandage was applied. Once reentering the abdominal cavity, the patient was experiencing increased sensation with
The skin was then closed with staples, and a pressure bandage was applied. Once reentering the abdominal cavity, the patient was experiencing increased sensation with remainder of the period, and the patient was then placed under general anesthesia via face mask for additional analgesia and sedation. Once the procedure was completed, the patient was awakened and then brought to the recovery room in stable condition.
