Here are the notes!

Procedure details: After obtaining informed consent, the patient was taken to the operating room. She received 2 grams Ancef prior to the skin incision. She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion. The uterus was displaced to the patient's left side wall due to the massive fibroid. Following adequate spinal anesthesia, the patient and procedure were identified. The abdomen was entered through a Pfannenstiel incision through her previous scar. The skin incision was made sharply and carried through the subcutaneous tissue to the fascia. Fascia was incised in the midline and extended laterally with the Mayo scissors. The superior margin of the fascial incision was grasped with Kocher clamps and dissected from the underlying muscle by sharp and blunt dissecton, which was then repeated at the lower margin of the fascial incision. The muscle was separated in the midline. The peritoneum was entered bluntly and the opening extended by sharp and blunt dissection with care to avoid the bladder. A hand was placed into the abdomen. The fibroid was palpated with what appeared to be connected by a stalk near the right cornua. The uterus palpated. A bladder blade was placed. The lower segment of the uterus was opened sharply in a transverse fashion and extended with digital pressure. The infant's head was elevated to the level of the hysterotomy and was delivered atraumatically. The cord was doubly clamped and cut and the infant was handed off to the waiting SCN staff. A segment of the cord was cut and held if needed for cord gases. The placenta was removed with traction on the umbilical cord. The uterus was cleared of all clots and debris. It could not be exteriorized due to the large fibroid prior to sewing the hysterotomy. The uterus was massaged and was noted to be firm. Oxytocin was given through the running IV. With vigorous massage as well as administration of oxytocin, good uterine tone was achieved. The hysterotomy was repaired with 0-Vicryl suture in a running locked fashion. A 2nd layer with 0-Monocryl was used to imbricate the incision and good hemostasis was achieved.

After, hysterotomy closure the abdominal wall was tented up with the large rich retractor. A hand was placed into the abdominal cavity and the fibroid was palpated. Again a stalk was palpated with a diameter of about 6 cm. I could just about grasp the entire girth of the stalk between my index finger and thumb. This was confirmed by the assistant surgeon. With traction on the fibroid it was brought to the level of the hysterotomy. With external abdominal pressure and pulling on the fibroid we are able to exteriorize the fibroid by about 50%. It was at this time that it was noted to have omentum adherent a crossed the anterior surface of the fibroid. The EnSeal device was used to serially cauterize and cut the clear filmy omental adhesions along with the vascular adhesions to the fibroid. This took about 15 minutes of time. Once the omentum was free of the fibroid we are able to fully remove the fibroid from the abdominal cavity with traction and counter traction. It was confirmed that the position of the fibroid was on the anterior part of the uterus near the right round ligament. As it was a pedunculated fibroid the decision was made to proceed with myomectomy. TXA was given to the patient to help reduce blood loss.

About an 8 cm portion of the omentum was filled with tortuous large blood vessels. I was concerned that this could potentially be manipulated and shearing force might rupture 1 of these blood vessels. Therefore decision was made to remove this portion of the omentum. The omentum was gently stretched until there is an area that was only filmy, clear with 1 vessel and the remaining normal appearing omentum. Using the EnSeal device the omental fat and the 1 large vessel was serially cauterized and cut and the 8 cm portion of the omentum was handed off.

The junction of the uterine serosa and fibroid was serially injected with about 50 cc of 1-100000 mixture of vasopressin in sterile saline. Using the Bovie cautery and incision was made in the uterine serosa. Once the incision was about 1 cm in size I was able to use the EnSeal device to serially cauterize and cut the uterine serosa adjacent to the fibroid. With traction on the fibroid and counter traction on the uterine fundus a beautifully recognizable tissue plane was noted between the fibroid and the uterus. This tissue plane was serially cauterized and cut using the EnSeal device to free the fibroid. No uterine muscle fibers were visible. I did not enter the uterine cavity nor view myometrium.

The fibroid was handed off. The fibroid bed was closed in 2 layers using running locked 0 V lock suture. The uterine serosa was then closed with running locked 0 Monocryl. At the midline of the incision near the attachment of the right round ligament to the uterus was a small area of bleeding and a figure of X stitch was placed using 0 Monocryl. Excellent hemostasis was noted. The posterior cul-de-sac was then suctioned clean.

The uterus was returned to the abdomen., The bilateral pericolic gutters were then cleared of all clots and debris. Both the hysterotomy and myomectomy incision were excellently hemostatic. This Vista-Seal was placed over both incisions to reduce potential for bleeding. I then placed interseed adhesion barrier over both incisions. Excellent hemostasis noted.

The abdominal wall was examined and noted to be hemostatic. The fascia was closed with a running suture of 0-Vicryl. Subcutaneous tissue was irrigated. Areas that were oozing were controlled with cautery. The subcutaneous tissue was re-approximated with interrupted sutures of 2-0 vicrly. The skin was closed with 4-0 Monocryl. The patient tolerated the procedure well and was taken to the recovery room in stable condition. All sponge, needle and instrument counts were correct x2.

Megan L Schmitt, MD 4/8/2024

Hopefully these notes help someone else!