My Surgery Report....

Finally, I have been given my report.

Room #: Attending: Frye, Lance MD

Admit Date: 07/29/14
Dischg Date: 07/29/14

DATE OF SERVICE: 07/29/2014


PREOPERATIVE DIAGNOSIS:
Endometriosis, site unspecified.

POSTOPERATIVE DIAGNOSES:
1.  Pelvic adhesions.
2.  Endometriosis.
PROCEDURE:
1.  Diagnostic laparoscopy.
2.  Fulguration of endometriosis.
3.  Peritoneal biopsy.
4  Lysis of adhesions.

FINDINGS:  Normal right ovary.

DISPOSITION:  Stable to PACU.

ESTIMATED BLOOD LOSS:  5 mL.

IV FLUIDS:  1000 mL

URINE OUTPUT: 100 mL

DRAINS: None.

PROCEDURE:  The patient was seen in the preop area.  Risks, benefits, indication
and alternatives of the procedure were reviewed with the patient.  The patient
agreed to proceed and signed the consent.  The patient was taken to the OR with
IV fluids running and SCDs to lower extremities and anesthesia was obtained
without difficulty.  The patient was placed in the dorsal supine position.  A
sponge stick was inserted into the vagina for uterine manipulation.  An
approximate 2-cm incision was made immediately inferior to umbilicus with a skin
knife.  The superior aspect of the umbilicus was grasped with 2 towel clamps.
The abdomen was tented up and Veress needle was inserted through the incision,
Veress needle felt to be in place, the position was checked by placing saline
drop test.  This was seen to further drop into the abdomen so the needle was
connected to CO2 gas, this was started at low flow setting and it was seen to
flow freely, it was then advanced to the high settings.  Abdomen was then
insufflated to an adequate distention of 15 mmHg.  The Veress needle was then
removed and a 5-mm trocar was then placed.  Laparoscope was inserted through
this port and then two 5 mm trocars were inserted in the bilateral lower
quadrants under direct laparoscopic visualization.  Trendelenburg position was
obtained to facilitate moving the bowel from out of the pelvis.  Next, a
atraumatic grasper was used to facilitate movement of the bowel out of the
pelvis, it was noted that the patient had multiple pelvic adhesions which were
lysed using scissors.  Hemostasis was noted.  Full examination using laparoscope
of the posterior cul-de-sac as well as the peritoneum in the pelvis was noted to
have multiple vesicular lesions.  Atraumatic grasper was placed on the vesicular
lesion and removed with scissors.  The specimen was sent to pathology.  Using
fulguration at the site of biopsy, hemostasis was noted, other areas suspicious
for endometriosis were fulgurated as well.  The pelvis was then copiously
irrigated with the suction irrigator and irrigation was removed, it was noted to
be completely hemostatic.  The ports were all then removed under direct
visualization.  The camera and laparoscopic ports were then removed and the
abdomen was desufflated.  All the ports were closed and the patient was taken to
recovery room in stable condition.  The patient was discharged home today with
ibuprofen and pain medication.  The patient before surgery as well as family was
discussed to have an appointment with Dr. Frye for postoperative check.


__________________________________________
Larissa Smith DO

__________________________________________
Lance T Frye M.D.
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Fulguration, also called electrofulguration, is a procedure to destroy and remove tissue.
vesicular lesions endometriosis