time of laparoscopy there was extensive intraabdominal pelvic adhesions extending from the umbilicus all the way to the pelvic floor with the bowel and omentum attached to the anterior wall, bladder and right ovary and tube. right ovary & tube itself was adherent to the pelvic sidewall right over the ureter. Omentum, large and small bowelwere adherent to the pelvic sidewall on the left, the bladder, the pelvic floor, the right ovary and tube,the right pelvic sidewall and into the right side of the intraabdominal wall. the ovary and tube on the right side were densely adhered to the pelvic side wall over the ureter and to the bladder and pelvic sidewall. the ovary itself was adhered to onto the psoas muscle which would be giving her the discomfrt she was feeling in her right leg and back.
procedure: patient draped for lap.small incision was made inferior to the umbilicus and trocar was thrust into cavity. trocar was removed and laparoscope was placed and visualization of the omentum. gas was instilled and adequate pneumoperitoneum, and extensive adhesive disease was noted. Photos were taken, and it was felt we had to proceed with exploratory as we could not determine tissue planes and dissect the ovary off pelvic sidewall. family notified and we proceeded with laparotomy.
old incision which was vertical, was removed all the way to the pubic symhysis. rectus mucsles were identified and diseected free off the rectus muscle all the way down from umbiliocus down to the symphysis.
skipped some...no bowel or bladder involved in in the peritoneal incision and this extended superiorly up to the umbiliocus and all the way down to the bladder as the mostly on the left side, and we found a clear path down in to the lower abdomen. we disseted the omentum, and small and large bowel off the anterior wa;; on the left side all the way down to the pelvic floor dissecting it free from the bladder, low pelvic floor and over the ovary and right pelvic sidewall. Once we were able to free up these adhesions we were able to dissect adhesions between the the bowel aswell as the colon from the pelvic sidewall recreating normal anatomy.left pelvic side looked to be free from disease except the adhesive disease. and we were able to free up completel the omentum. small and large bowel from all its adhesive points. bladder was not injured and we felt we were able to remove all adhesions at this point. the omentum looked oozy along one edge and did not seem to extend down into the pelvis. omentum was small and we removed about 40 % of the omentum to help prevent further adhesion sformation.at a later time.
we identified the ovary and found it to be 5 to 6 cm across with multiple ovarian cysts felt to be hem in nature. the ovary itself was adhered to the ureterand the psoasa muscle and we were unable to identify tissue planes.decsion was mad at that point because risk of further adhesions formation and the multiple cysts to remove tyhe ovary.patient was well aware of that. she has had problems with cysts in the past, and I feel leaving the ovary would subject her to reccurence adhesive disease, ovarian cysts, and her pelvic pain.the ovary was densely adhered and pelvic side wall and bladder,, there was some bledding points,along right pelvic sidewall and we stayed there for ten minutes with warm wrap in that area.
I will send my second surgery tomorrow, it is more involved than this one. Kath, do you understand this, I skipped some things I hope were not important I am not fast typer!
Toni