Laparoscopy:
Details of Procedure:

After indication and procedure were reviewed with the patient, she was taken back to the operating room where

Cefotetan 2g IV was given

and SCDs were placed and working before general anesthesia was induced via endotracheal intubation.

Patient was prepped and draped in the normal sterile fashion in the dorsal lithotomy

position using betadine on vagina/perineum and Chloraprep on the abdomen

with Allen stirrups with care to align each ankle to knee to opposite shoulder with no pressure points on knees/ankles/wrists/elbows.

A Foley catheter was placed.

A speculum was placed in the vagina and a single-tooth tenaculum was attached to the anterior lip of the cervix and endometrial cavity was sounded to

cm. Cervix was sequentially dilated using Hank dilators to size 21.

*1mL of dilute

4mL Lymphazurin in 2mL sterile water

25mg stock ICG powder in 20mL sterile water

1mL methylene blue stock solution in 9mL sterile water

was injected @ 3:00 and 9:00 positions of cervix at 1cm and superficial depth, using a total of 4mL of this solution.

A

-sized

uterine manipulator was placed. Speculum and tenaculum were then removed from the vagina.

Next we turned our attention to the abdomen where intraperitoneal access was gained via

Veress needle placement at umbilicus

*direct optical trocar entry by first making an incision at

, then placing a 5mm, 0-degree lens on the laparoscope via an optical trocar and inserting the port and laparoscope through the incision under direct visualization until peritoneal placement was obtained.

Opening pressure was

mmHg and pneumoperitoneum was obtained and maintained at 15mmHg throughout the case. A periumbilical incision was made with scalpel after injecting site with local anesthetic and a

mm port with optical trocar was placed under direct visualization until peritoneal placement was obtained. This served as our camera port for the case.

Exploration of the abdomen revealed

Exploration of the pelvis revealed

Next, we placed additional trocars at

under direct visualization by first injecting the proposed trocar site using local anesthetic then using a scalpel making an appropriate sized incision then inserting the trocar.

Intuitive Surgical da Vinci Xi robotic platform was docked with

on lateral left arm

on medial left arm

on medial right arm

on lateral right arm.

Physiologic adhesions from the descending colon to the left pelvic sidewall were lysed using blunt and sharp dissection using the LigaSure device.

round ligament was divided using LigaSure device and the peritoneal incision extended cephalad (parallel to infundibulopelvic ligament) and caudad (towards the vagina) using the LigaSure/SILS hook device.

ureter was identified

. The

infundibulopelvic ligament was divided using the LigaSure device well away from the ureter. We divided the remaining peritoneal attachments from the

side of the uterus and adnexa to the

pelvic sidewall using the SILS hook/LigaSure device. We skeletonized the

uterine artery by bluntly developing the peritoneal space anterior and posterior to it and then divided it with the LigaSure device.

We then turned our attention to the other side and divided the

round ligament using LigaSure device and the peritoneal incision extended cephalad (parallel to infundibulopelvic ligament) and caudad (towards the vagina) using the LigaSure/SILS hook device.

ureter was identified

. The

infundibulopelvic ligament was divided using the LigaSure device well away from the ureter. We divided the remaining peritoneal attachments from the

side of the uterus and adnexa to the

pelvic sidewall using the LigaSure/SILS hook device. We skeletonized the

uterine artery by bluntly developing the peritoneal space anterior and posterior to it and then divided it with the LigaSure device.

We further developed the vesicouterine/vesicocervical/vesicovaginal space by blunt dissection and using the SILS hook device until the pearly white pubocervical fascia overlying the vagina can be seen and cleared of all fatty tissue. Posteriorly, we divided bilateral uterosacral and cardinal ligaments using LigaSure/SILS hook device.

Once we were able to circumferentially visualize the indentation made by the uterine manipulator cup, we proceeded with the colpotomy using SILS hook device.

Uterus was delivered vaginally. Vaginal cuff was closed using 0 VLoc-180 suture using EndoStitch device in continuous running fashion and 1 additional backbite was taken to ensure anchorage. Needle was removed from the peritoneal cavity and accounted for. Colpotomy was tested and found to be adequately closed.

We proceeded with extending the peritoneal incisions and exposed the fibrofatty tissue overlying the

external iliac vessels. We cleared off all fibrofatty tissue overlying the

external iliac artery after identifying the genitofemoral nerve and preserved the nerve. This was done using blunt traction as well as LigaSure/SILS hook device. We continued our dissection laterally to the circumflex iliac vein, medially to the ureter, cephalad to the lower half of the common iliac artery, and caudad to the super vesical artery. We mobilized the

external iliac artery and vein and cleared off all fibrofatty tissue posterior to the vessels and approached the obturator space. We identified the obturator nerve and cleared all fibrofatty tissue superficial to this and then replaced the mobilized external iliac vessels and completed clearing off the remaining fibrofatty attachments. All these contents were sent as

pelvic lymph nodes. The

ureter was visualized and noted to be well away from areas of dissection.

We repeated this process on the

and extended the peritoneal incisions and exposed the fibrofatty tissue overlying the

external iliac vessels. We cleared off all fibrofatty tissue overlying the

external iliac artery after identifying the genitofemoral nerve and preserved the nerve. This was done using blunt traction as well as LigaSure/SILS hook device. We continued our

dissection laterally to the circumflex iliac vein, medially to the ureter, cephalad to the lower half of the common iliac artery, and caudad to the super vesical artery. We mobilized the

external iliac artery and vein and cleared off all fibrofatty tissue posterior to the vessels and approached the obturator space. We identified the obturator nerve and cleared all fibrofatty tissue superficial to this and then replaced the mobilized external iliac vessels and completed clearing off the remaining fibrofatty attachments. All these were sent as

pelvic lymph nodes. The

ureter was visualized and noted to be well away from areas of dissection.

We then extended the right pelvic peritoneal incision cephalad. We removed all fibrofatty tissue bound caudad by upper half of common iliac artery, medially by aorta/IVC, laterally by ureter and cephalad by

. These were sent as

para-aortic lymph nodes. The

ureter was visualized and noted to be well away from areas of dissection.

On the other side, we similarly extended the

pelvic peritoneal incision cephalad and removed all fibrofatty tissue bound caudad by upper half of common iliac artery, medially by aorta, laterally by ureter, and cephalad by

. These were sent as

para-aortic lymph nodes. The

ureter was visualized and noted to be well away from areas of dissection.

Abdomen was irrigated and drained. Hemostasis was noted to be excellent. >10mm port site fascial incisions were closed using 0-Vicryl.

10mL of local anesthetic was instilled intraperitoneally. Abdomen was desufflated while all trocars were removed under direct visualization except the camera port, which was used to further desufflate the abdomen by asking the anesthesia team to performing Valsalva maneuver for the patient. Port site skin incisions were closed using 4-0 Monocryl sutures in subcuticular fashion then reinforced using Mastisol, steri-strips and surgical bandages. Incisions were then infiltrated with the remaining local anesthetic.

Sponge, lap, needle counts were correct x 2.

Foley catheter was

. Patient was cleansed, awakened, extubated and brought to the recovery room in stable condition

========================
Mediport
Findings:

1. *** vein accessed successfully

2. Total fluoroscopy time *** seconds

Details of Procedure:
After indication and procedure were reviewed with the patient, she was taken back to the operating room where *** was begun. Her neck, chest and shoulders were then prepped and draped in the normal sterile fashion in the dorsal supine position using Chloraprep. After infiltration of local anesthetic (1% lidocaine + 0.25% bupivicaine) into the subcutaneous tissue, a finder needle was placed percutaneously under ultrasound guidance to access the *** vein. Successful aspiration of dark blood was obtained, and the guidewire was passed under fluoroscopic guidance using the Seldinger technique. We dilated the skin using a size 11 scalpel and placed the dilator over the wire, then removed the wire. We placed the catheter under fluoroscopic guidance. Next we made a subcutaneous pocket on the *** chest, above the fascia, using a scalpel for the skin incision and dissection both bluntly and with electrocautery device. We tunneled the catheter subcutaneously using the tunneling device and secured it to the mediport using the keeper after trimming the catheter to the appropriate length under fluoroscopic guidance. The line tip was in good position under fluoroscopy. The port was access with a Huber needle and withdrew and flushed well with dilute then full-strength heparin. Hemostasis was excellent. We closed the incision using 3-0 Monocryl in the deep dermal layer then subcuticular layer using 4-0 Monocryl reinforced with Dermabond adhesive.
Sponge, lap, need counts were correct x 2.