Spinal anesthesia inducted

Patient was placed in supine position

A foley catheter is placed
Abdomen antiseptically and aseptically prepared
Infraumbilical midline skin incision done and was carried down to the peritoneum
A self-retaining retractor was placed
Pelvis and abdomen are visually and manually explored, and the bowel is packed from the operating
field
Each fallopian tube and uteroovarian ligament are clamped with Curved Kelly clamps lateral to the
uterus
Both round ligaments were clamped, cut and ligated with transfixion sutures, Vicryl O, placed
approximately 1cm proximally and another suture 1cm distally .
Bladder dissected away from the cervix
Fallopian and tube and ovaries are grasped with Babcock clamp and elevated away from the
infundibulopelvic ligament
Heaney clamps are placed medial to the ovary and fimbriae.
The segment between the medial Heaney clamps and Curved Kelly clamp (lateral to the fallopian tube
and uteroovarian ligament) is incised. A free tie of Vicryl-O is placed around the tissue pedicle held by
the 2 Heaney clamps
The lateral Heaney clamps is removed after the suture is secured, then Vicryl-O is placed around the
remaining clamp which finally freed the adnexa from the uterus.
Abdominal incision was extended at the level of umbilicus to widen the operative site.
Fallopian and tube and ovaries are grasped with Babcock clamp and elevated away from the
infundibulopelvic ligament
Infundibulopelvic ligament was isolated and then Heaney clamps were placed, transected and ligated
with a transfixing suture which freed the adnexa from the pelvic wall.
Vesicouterine fold is grasped and elevated
Sharp dissection on the connective tissue within the vesicouterine space is done with metzenbaum
scissors.
Uterine artery is then identified along the lateral aspect of the uterus at the level between the isthmus
and cervix.
2 Heaney clamps are placed on the uterine vessels inferiorly to the planned site of transection
Another Heaney clamp was place above the planned site of transection.
Then, uterine vessels are sharply transected, and ligated with Vicryl-O suture.
Ahesiolysis was done between the posterior portion of the uterus and the sigmoid colon
Cardinal ligament is identified, clamped with a straight Heaney, transected and ligated with a Vicryl O.
Same procedure was performed to the contralateral ligament.
Upward traction was applied to the uterus to visualize the uterosacral ligaments, grasped with a straight
Heaney clamp, transected and ligated with Vicryl-O suture.
The most inferior level of the cervix was palpated
Both anterior and posterior vaginal walls were grasped with curved Heaney clamp just below the cervix.
Vaginal tissue above the clamp was incised.
Vicryl-O sutures were placed below the Heaney clamp and removed.
Upward and lateral traction with hemostats were applied to elevate the vaginal cuff
Vaginal pack soaked with betadine was placed in the vagina.
Vaginal interlocking sutures placed around the vaginal margin using Vicryl-O delayed-absorbable suture.
Operative site checked for bleeders
Abdomen was closed layer by layer
Parietal peritoneum is closed using Vicryl 2-0
Muscle and fascia were closed from one end to the other using a continuous running suture
with Vicryl 1-0
Subcutaneous layer is closed using a continuous running suture with Vicryl 1-0
Skin is closed with a subcuticular stitch using Vicryl 1-0
Betadine solution applied
Top dressing applied
Patient transported to the recovery room in fair condition

Intraoperative findings:
-Uterus enlarged to 16 week size, cut section showed submucous myoma approximately
10x10cm
-Right adnexa adherent to the cul de sac, cut section showed solid component approximately
6cm in size with purulent discharges and necrotic tissues
-Left adnexa is cystic approximately 4xxcm cystic with blackish content

INTRAOPERATIVE FINDINGS:

Uterus was measured ____ by _____cm, retroverted, with multiple myometrial masses. The largest
myoma is located serosally in the anterior fundus which measures _____by _____ by ______cm on cut
section, off-white color, rubbery to firm in consistency and displayed a whorled pattern. Similar masses
were found on the lateral uterine corpus ranging from 2-3cm in diameter
Cervix is smooth and