LOOKING FOR A CODE FOR:
1. Vaginal agenesis.
2. Cervical agenesis.
1. Exam under anesthesia.
2. Exploratory laparoscopy.
3. Exploratory laparotomy.
6. Abdominal hysterectomy.
1. Absent vagina.
2. Fibrous cervical tissue not communicating with endometrial cavity.
3. Two separate analogous uteri with left greater than right.
Normal ovaries bilaterally.
ANESTHESIA: General endotracheal anesthesia.
SPECIMENS TISSUE REMOVED: Bilateral analogous uteri.
ESTIMATED BLOOD LOSS: Less than 100 mL.
IV FLUIDS: 3 L.
URINE OUTPUT: 850 mL.
COUNTS: Correct x3.
DICTATION: The patient was taken back to the operating
room where she was placed in dorsal lithotomy position and prepped and draped
in normal sterile fashion after induced under anesthesia. A 5 mm
infraumbilical port placed and trocar introduced using an Excel trocar under
direct visualization. Findings as noted above. Lateral 5 mm trocar sites
placed under direct visualization with transillumination of the skin in order
to avoid the epigastric vessels. Patient was placed in Trendelenburg and
bowels were moved cephalad in order for better visualization. While operator
was continuing to look from above, the attending went down below the legs and
opened up the vaginal cuff and dissected the vaginal tissues posterior to where
the cervical entrance was thought to be and attempts were made to dissect through connective tissue in order to reach the cervical layer, however, this proved to be unsuccessful. After several attempts this was aborted and attention was then returned to the abdomen where a laparotomy was
made. A skin incision was made in a Pfannenstiel fashion and carried down to
the underlying layer of the fascia with the Bovie. Bovie was used to nick the
fascia in the midline and to cut the fascia while it was undermined with the
Adson clamp. Kocher clamps x2 used to grasp the superior aspect of the fascial
incision and the underlying rectus muscles dissected off sharply with the
Bovie. The inferior aspect was handled in a similar manner. Rectus muscles
were separated in the midline and peritoneum grasped with hemostats and entered
sharply with the Metzenbaum scissors. Once inside the peritoneal cavity,
stretching was used to separate the muscles and the peritoneum. The patient
was again placed in Trendelenburg and bowel was packed away with tagged
laps. Self retaining retractor used for better visulaization. Uteri were again identified and left uterus was grasped and transected across the fundus. Area was seen where the left fallopian tube
communicated with the left hemiuterus; however, there is no direct connection
between the fibrous cervical tissue and the endometrial cavity. Secondary to not having a chance of creating a successful outflow tract this at that point Dr. left the OR to discuss the findings with the family. The plans were made to proceed with hysterectomy to remove the
uterine tissue. The round ligament on the left was grasped and suture ligated
and the leafs of the broad ligament were then opened. Window was created
beneath the uterine ovarian ligament and Heaney clamps x2 placed across the
window. Mayo scissors were used to cut between the 2 clamps and the pedicle
was then suture ligated with 0 Vicryl in a free pass and then stick tied with 0
Vicryl. Excellent hemostasis was noted. The pedicle was then skeletonized and
the Heaney clamps were placed across the uterine artery. Pedicles were created
using Mayo scissors and this was suture ligated x2 to secure the pedicle.
Another straight Heaney was used to create a pedicle along the cervical tissue
and then this was suture ligated with 0 Vicryl and then a curved clamp placed
across the base below the cervical fibrous tissue and this was suture ligated
in a modified Heaney manner. Good hemostasis was noted. Attention was then
turned to the right hemiuterus. In a similar manner the uterine ovarian
pedicle was ligated with Kelly clamps x2 and Mayo scissors were used to cut the
intervening tissue and this pedicle was suture ligated. Another Kelly clamp
was used to clamp along the broad ligament along the side of the uterus. This
again was suture ligated and then a final clamp was placed across the uterine
tissue and the right hemiuterine was free and this was free tied. Copious
irrigation was performed. Attention was then turned below and a space was
created posterior and the posterior cul-de-sac was noted to be free enough to
pull the peritoneum down to create a vaginal oriface. The abdominal
peritoneum was then suture ligated to the vaginal mucosa in an interrupted fashion in a circumferential pattern. Hagar dilator was placed vaginally to
maintain the window into the abdominal cavity and a pursestring closure was
done abdominally of the peritoneum above the dilator to create the neovagina.
Good results were performed with 6 cm vagina created at the end of procedure.
All laps were removed from the abdominal cavity. The muscles were
reapproximated using 0 Vicryl in figure-of-eight fashion. The fascia was
closed 0 Vicryl in a running fashion. The subcutaneous layers were
reapproximated using a 0 Vicryl in a subdermal fashion. The skin was closed
with 4-0 Monocryl in subcuticular fashion, as well as the 3-5 mm laparoscopic
sites. The patient tolerated the procedure well. Estrogen
vaginal cream was placed vaginally and the patient was taken awake
in a stable condition to recovery room.