PROCEDURE:
1. Laparoscopic-assisted robotic tubal reanastomosis.
2. Chromotubation .
3. Intraoperative consult with colorectal surgeon,
ESTIMATED BLOOD LOSS: 100 mL.
URINE OUTPUT: 125 mL.
IV FLUID: 3000 mL.
DRAINS: Foley removed at end of procedure.
COMPLICATIONS: None.
INDICATIONS: A 29-year-old P3-0-1-3 with history of
postpartum Parkland tubal ligation who desires future pregnancy, declines in
vitro fertilization prior to tubal reanastomosis attempt.
FINDINGS: Normal post Parkland tubes bilaterally.
Right tube with adhesions to the round ligament and pubic symphysis, normal
fimbriae bilaterally, dye present through bilateral tubes after anastomosis,
bilateral normal ovaries, uterus globular, 10-12 week size. A large 5 cm liver
mass in lobe 4B. This mass was examined by colorectal surgeon, who recommended outpatient follow-up with liver protocol MRI.
SPECIMEN REMOVED: Bilateral tubal resection portions.
TECHNIQUE: The patient was taken to the operating room
where general endotracheal anesthesia was initiated without complication. The
patient was placed in Allen stirrups in the dorsal lithotomy position and arms
were tucked at her side. She was prepped and draped in the normal sterile
fashion. A Foley catheter was inserted into the bladder. A metal bivalved
speculum was placed in the vagina and the cervix was visualized anteriorly. A
single-tooth tenaculum was placed on the anterior lip of the cervix. Attempt
was made to pass the sound through the cervix which was unsuccessful, so Pratt
dilator was used to dilate the cervix and then the sound was able to pass
through with ease. She sounded to 10 cm. A HUMI uterine manipulator was then
advanced into the uterus. The tenaculum and speculum were removed from the
vagina. Attention was then turned to the abdomen where a supraumbilical
incision was made approximately 5 cm above the umbilicus. A 12 mm port was
placed under direct visualization with the laparoscope. Abdomen was then
insufflated with CO2. Lateral ports were then placed, a right lateral port was
placed approximately 10 cm lateral to the umbilical port, this was also a 12 mm
port. An additional left lateral port was also placed 10 cm from the umbilical
port. This is an 8 mm port and an additional 8 mm port was placed
approximately 10 cm below the left lateral port. Another 8 mm port was placed
in the right lower quadrant. These were all done under direct visualization.
The pelvis was then surveyed with the above findings. At this time the robot
was docked and the arms were connected to the ports. Instruments were then
placed through the ports. Attention was turned to the left tube which was
gently grasped and elevated. Both segments of the tube were visualized.
Portions of the left tube at the site of the previous ligation were excised to
leave healthy tube. A #2 nylon was used as a stent to connect the 2 portions
of the tube. The tube was then reapproximated first with 5-0 Vicryl to
reapproximate the tubal serosa adjacent to the tubes to decrease tension on the
tubes. The tube was then reapproximated with 6-0 Vicryl in a circumferential
manner in the tissue just adjacent to the lumen and then 5-0 Vicryl was used to
reapproximate the serosa in interrupted fashion around the tube. This stent
was then removed from the tube. Attention was then turned to the right tube
which was noted to be adhesed to the round ligament and the pubic symphysis.
These adhesions were taken down with the bipolar and scissors. The tube was
then free. In a similar fashion the ends of the tube at the site of the old
tubal ligation were excised to leave healthy tube. A #2-0 nylon was used as a
stent and guided through both ends of the tube to help reapproximate. 5-0
Vicryl was used to reapproximate the tubal serosa adjacent to the tubes to
decrease tension on the tubes in an interrupted fashion. The tube was then
reapproximated with 6-0 Vicryl in a circumferential manner by suturing the
tissue adjacent to the lumen, then 5-0 Vicryl was used to reapproximate the
serosa in an interrupted fashion. The stent was then removed from the tube.
At this time indigo carmine was injected through the HUMI into the uterus and
dye was noted to flow out of bilateral tubes. The uterus and tubes were
reinspected. Areas of the uterine serosa were noted to be oozy, this was
stopped with electrocautery and noted to be hemostatic. The pelvis was then
copiously irrigated with saline and suctioned and the area was hemostatic. The
instruments were removed from the ports and the robot was undocked. The
laparoscope was then advanced into the umbilical port to survey the pelvis
which again was noted to be hemostatic. Surveillance of the upper abdomen was
done which found a large 5 cm liver mass on the 4B lobe. Colorectal Surgery, scrubbed in to examine the mass and it was determined that
the patient would require outpatient imaging with MRI. The remainder of the
upper abdomen appeared normal. The laparoscope was then removed from the port
and the remaining instruments were all removed. The ports were then removed
from the abdomen. The umbilical port and right lateral port sites fascia were
reapproximated with 0 Vicryl with a single figure-of-eight stitch. The
subcutaneous tissue of these ports were reapproximated with 3-0 Vicryl in an
interrupted fashion. All remaining ports skin were closed with 4-0 Monocryl in
a subcuticular fashion. Steri-Strips and bandages were applied to each site.
Attention was then turned to the vagina where the speculum was inserted and the
HUMI was removed. Cervix was hemostatic. The speculum was removed. Foley
catheter was then removed. The patient tolerated the procedure well. Sponge,
lap and needle counts were correct x3. The patient was awakened from general
anesthesia and taken to the recovery room in stable condition.
