DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Elective sterilization.
POSTOPERATIVE DIAGNOSIS: Elective sterilization.
OPERATION PERFORMED: Laparoscopy with double puncture and bipolar coagulation of both tubes.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe
ANESTHESIA: General anesthesia.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old G3, P3 female who was counseled extensively on permanent sterilization procedure. The patient was offered reversible methods of birth control like Depo-Provera, the pill, IUD, NuvaRing, and condoms, but the patient wanted her tubes tied.
DESCRIPTION OF OPERATION: The patient was taken back to the operating room and placed in the dorsal lithotomy position and given general anesthesia. Pelvic examination before the procedure revealed a cervix that was normal and a uterus that was anteverted, anteflexed, normal in size. No adnexal masses were appreciated. The cul-de-sac was free. The vagina and abdomen were prepped and draped in the usual fashion for laparoscopic tubal ligation. The anterior lip of the cervix was grasped with an Allis clamp, and Kocher clamp was placed within the uterine cavity. The surgeon and assistant then changed gloves.
An infraumbilical stab incision was made. A 5 mm bladeless trocar was now inserted into the abdominal cavity and 3.5 liters of CO2 was insufflated. An adequate pneumoperitoneum was established. A second puncture was made in the lateral abdominal wall by transillumination of the abdomen, and a left stab incision was made and a second 5 mm bladeless trocar was inserted under lower cavity. Inspection of the pelvic contents revealed that the tubes were anteverted, anteflexed, normal size. The right tube was traced from the right cornu to its fimbria. Starting about 0.5 cm distal to the right cornu, the tube was treated and bipolar coagulated in four adjacent areas. Similarly, on the left side, the left tube was traced from the left cornu to its fimbria, starting 0.5 cm distal to the left cornu. The tube was picked up and bipolar coagulated. CO2 was allowed to be evacuated via both sleeves. Both sleeves were removed.
Both stab incisions were infiltrated with 0.5% Marcaine with 1:200,000 epinephrine and 5 mL was infiltrated in each stab incision. Both stab incisions were closed with a subcuticular stitch of 4-0 Monocryl. The patient tolerated the procedure fairly well. The patient was escorted to the recovery room in satisfactory condition.
