ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE

COMMAND
VICTORIANO LUNA MEDICAL CENTER
V Luna Road, Quezon City

AFPMC - 032
CLINICAL RECORDS
OPERATION REPORT

PRE-OPERATIVE DIAGNOSIS
Gravida 3 Para 3 (3-0-0-3) Abnormal Uterine Bleeding – Multiple Myoma
Uteri
SURGEON FIRST ASSISTANT SECOND ASSISTANT
DR CAGUITLA DR MENDEZ DR HILAB
ANESTHESIOLOGIST TYPE OF ANESTHESIA TIME BEGUN 0949H
DR DE LEON /DR FELIX CEA TIME ENDED 1405H
SURGICAL NURSE INSTRUMENT NURSE TIME OP BEGUN 1005H
MR JOVENAL TIME OP ENDED 14050H
DRAINS (KIND NO.) SPONGE COUNT SPECIMEN (ORGAN & REGION)
None Complete Uterus, cervix and fallopian tubes
OPERATIVE DIAGNOSIS:
Gravida 3 Para 3 (3-0-0-3) Multiple Myoma Uteri, Submucous and
Intramural Types; Total Abdominal Hysterectomy with Bilateral
Salpingectomy under Continuous Epidural Anesthesia
OPERATION PERFORMED:
Total Abdominal Hysterectomy with Bilateral Salpingectomy under
Continuous Epidural Anesthesia
DESCRIPTION OF OPERATIVE: (MAJOR) (MINOR)
(Include Gross Findings)
- Induction of Continuous Epidural Anesthesia
- Patient placed in supine position
- Indwelling Foley catheter inserted aseptically, hooked to urine bag.
- Internal examination revealed cervix is short, firm, closed, uterus
enlarged to 4 months size, no adnexal mass noted
- Asepsis and antisepsis done
- Sterile drapes were placed.
- Infraumbilical midline incision was done on the skin deepened down to
the subcutaneous tissue, fascia and peritoneum.
- Self-retaining retractor was placed and bowel packs were applied.
- Inspection and palpation of abdominal and pelvic organs was done.
- Kelly clamps were applied on the cornual area of the uterus and used
for traction.
- The left round ligament identified, grasped with straight Ochsner, cut,
suture ligated with Vicryl 1-0 suture and tagged.
- The right round ligament identified, grasped with straight Ochsner, cut,
suture ligated with Vicryl 1-0 suture and tagged.
- Anterior leaf of the broad ligament opened and incised to the point of
the vesicouterine fold.
- The antimesenteric border of the left fallopian tube was held with a
babcock forceps until the whole length of the fallopian tube was
exposed. Serial clamping with curved Kelly forceps, cutting, tying and
suture ligation using atraumatic vicryl 2-0 was done on the left
mesosalpinx up to the uterotubal junction.
- The antimesenteric border of the right fallopian tube was held with
Babcock forceps until the whole length of the fallopian tube was
exposed. Serial clamping with curved Kelly forceps, cutting, tying and
suture ligation using atraumatic vicryl 2-0 was done on the right
mesosalpinx up to the uterotubal junction.
- The courses of the bilateral pelvic ureters were visualized and checked.
- The left utero-ovarian ligament was identified and triply clamped with
curved Ochsner with the first clamp applied distal to the uterus and the
succeeding second and third clamps were placed proximally towards
the uterus, and the ligament was cut between the second and third
clamps. A free tie using vicryl 1-0 was placed around the most distal
clamp and a Transfixion suture using vicryl 1-0 was placed behind the
middle clamp. The right utero-ovarian ligament was identified and triply
clamped with curved Ochsner with the first clamp applied distal to the
uterus and the succeeding second and third clamps were placed
proximally towards the uterus, and the ligament was cut between the
second and third clamps. A free tie using vicryl 1-0 was placed around
the most distal clamp and a Transfixion suture using vicryl 1-0 was
placed behind the middle clamp.
- Bladder mobilization done: the bladder was pushed down and deflected
off from the lower uterine segment and upper cervix.
- The posterior leaf of the broad ligament was pushed with fingers, and
cut with Metzenbaum scissors up to the point of origin of the
uterosacral ligaments.
- The left uterine vessels were identified, isolated and freed off from filmy
tissues around it. Two curved Ochsner clamps were placed
perpendicularly directed at the level of the isthmus with the third,
Straight Ochsner clamp placed above the two curved Ochsner clamps
parallel to the corpus. It was cut between the second and third Ochsner
clamps, and the pelvic side was doubly suture ligated with vicryl 1-0.
The right uterine vessels were identified, isolated and freed off from
filmy tissues around it. Two curved Ochsner clamps were placed
perpendicularly directed at the level of the isthmus with the third
straight Ochsner clamp placed above the two curved Ochsner clamp
parallel to the corpus. It was cut between the second and third Ochsner
clamps, and the pelvic side was doubly suture ligated with vicryl 1-0.
- The pubocervical fascia was pushed downwards together with the
bladder.
- The left side of cardinal ligament was identified and clamped close to
the cervix, cut and suture ligated with vicryl 1-0. The right side of
cardinal ligament was identified and clamped close to the cervix, cut
and suture ligated with vicryl 1-0.
- The uterosacral ligaments on both sides were identified and were
clamped, cut and suture ligated with vicryl 1-0.
- Straight Ochsner clamps were placed across each of the right and left
vaginal angle. The uterus and cervix were severed from the vagina
using Mayo scissors.
- Vaginal margins were clamped with Allis forceps.
- Betadinized gauze was inserted inside the vagina.
- Vaginal angles were sutured using Heany’s suture with vicryl 1-0.
- A continuous interlocking suture was placed around the vaginal cuff
using Vicryl 1-0, starting at the midpoint of the anterior vagina wall and
carried around to the stumps of the cardinal and uterosacral ligaments
that are sutured into the angles of the vagina leaving the vaginal cuff
open.
- The anterior and posterior vaginal walls were apposed by one simple
interrupted suture using Vicryl 1-0 at the midline.
- Ureters were identified bilaterally and checked.
- Bladder and cul de sac peritoneum approximated with simple
continuous sutures using atraumatic chromic 2-0.
- Pelvic organs were re-inspected.
- Peritoneal washing done.
- Bleeders checked and ligated. Hemostasis observed.
- Balfour and visceral packs removed.
- Operative sponge, instruments and needles count verified complete.
- Abdomen closed in layers:
o Peritoneum- closed continuously using chromic 2-0
o Fascia – closed with continuous interlocking using Vicryl 1.
o Subcutaneous tissue – closed continuously using Vicryl 2-0
o Skin – subcuticularly closed using Vicryl 4-0
- Incision site cleansed and painted with Betadine.
- Sterile dressing was applied.
- Betadinized gauze removed per vagina.
- Estimated blood loss – 300cc
- Patient tolerated the procedure well.

INTRAOPERATIVE FINDINGS:

There was no ascites. The liver, gallbladder, subdiaphragmatic surface,

stomach, spleen, kidneys, omentum, appendix, and intestinal surfaces
were smooth and grossly normal on inspection and palpation.
The uterus was enlarged measuring 11.0 x 10.0 x 7.0 cm with smooth
serosal surface. On cut section, there were 2 nodular masses: 1) within the
endometrial cavity measuring 8.0 x 7.0 x 5.0 cm and 2) posterofundal area
measuring 7.0 x 5.0 x 5.0 cm. Cut section of the masses revealed whorl
like pattern suggestive of myoma uteri. The endometrial cavity measures
6.0 cm while the endometrial lining measures 0.3 cm. The cervix measures
5.0 x 3.0 x 3.0 cm which on cut section revealed cystic lesions measuring
0.5 cm filled with clear fluid.
Both ovaries were grossly normal. The right fallopian tube measures
3.5 x 0.5 x 0.5 cm which on cut section is grossly normal. The left fallopian
tube measures 5.0 x 5.0 x 6.0 cm which on cut section is grossly normal.

Signature of Surgeon: Date:

ANGELA MAY R CAGUITLA MD 02 JULY 2019
Patient’s Age: 41 years old
CONSULTANTS: DR RAMOS/DR MENDEZ