OB-GYN Medical Transcription Operative / Surgical Sample Reports For Medical Transcriptionists


OPERATIONS PERFORMED:

1.  Repeat low segment transverse cesarean section.
2.  Bilateral Pomeroy tubal ligation.

DESCRIPTION OF OPERATIONThe patient was taken to the operating room after being administered an epidural anesthetic, placed in the supine position, prepped and draped in a sterile fashion with a wedge under the right hip.  A Pfannenstiel skin incision was made and carried down through layers along the old incision line.  Peritoneal cavity was entered, and the peritoneal incision was extended vertically.  Bladder flap was developed; however, a lot of scarring along the bladder line prevented development of much of a bladder flap, so a transverse incision was made just above the level of the bladder reflection.  This incision was then extended laterally with bandage scissors.  Baby was then delivered via vertex presentation without difficulty.  The baby was suctioned, cord clamped and cut, and handed to the pediatric team in attendance.  Placenta was then delivered manually.  Uterus was closed in one layer with #1 chromic continuous interlocking suture.  There were additional figure-of-eight sutures placed along the incision line for hemostasis.  Attention was now focused to the tubes, and the tubes were elevated in the medial portion and doubly suture ligated with #0 plain catgut suture.  Tubes were then transected by ligature.  The uterus was then delivered back in the abdominal cavity and tube inspected and found to be still fine after the tubal ligation.  The pelvis was irrigated and small bleeding points were cauterized.  Lap and instrument counts were correct.  The muscle was reapproximated in the midline with interrupted #2-0 Vicryl suture.  The fascia was then closed with #0 Vicryl suture on inferolateral aspect of the incision to the midline and other side.  Subcutaneous tissue was found to be dry, and the skin was then closed with staples.  The patient tolerated the procedure well and was transferred to recovery in satisfactory condition.

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PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 40 plus weeks.
2. Active labor.
3. History of two previous cesarean sections.

POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 40 plus weeks.
2. Active labor.
3. History of two previous cesarean sections.

OPERATION:  Repeat low transverse cesarean section.

FLUIDS:  2500 mL lactated Ringer.

ESTIMATED BLOOD LOSS:  300 mL.

URINE OUTPUT:  125 mL, clear and yellow.

DESCRIPTION OF OPERATION:  The patient was identified and taken to the operating room. Appropriate anesthesia was administered. The patient was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion. Following that, a low Pfannenstiel skin incision was made with a #10 scalpel. This incision was carried down to the underlying layer of fascia with the scalpel. The fascia was then nicked in the midline with the scalpel. This fascial incision was then extended laterally with the Mayo scissors and pickups with teeth.

Following that, the superior aspect of the fascial incision was grasped with straight Kocher clamps x2, tented up from the rectus muscles below and dissected away sharply with the scalpel and Mayo scissors. This was repeated similarly to the inferior aspect of the fascial incision. Following that, the peritoneum was identified below, grasped with hemostat x2, and entered sharply with Metzenbaum scissors. After appropriate visualization of the bowel and bladder, the peritoneal incision was extended superiorly and inferiorly. The bladder blade was then placed inferiorly and the vesicouterine peritoneum tented up with the smooth pickups, incised with the Metzenbaum scissors, and this incision was extended laterally.

Following that, the bladder blade was replaced deflecting the bladder anteriorly and inferiorly. The #10 scalpel was taken in hand again, and a 3-cm low transverse area incision was then made. This incision was then extended laterally. Following that, the infant’s vertex was mobilized and delivered through the incision in a direct OP position. The infant’s nasopharynx was suctioned with the bulb syringe and then the rest of the infant was delivered along with fundal pressure.

Following that, the infant’s cord was clamped and cut and the infant was handed off to the awaiting pediatricians. Following that, the placenta was spontaneously expressed. The uterus was then exteriorized and cleared of all clots and debris. The uterine incision was repaired with #1 chromic in a running-locking fashion. The uterus was then returned to the abdominal cavity, and the abdominal cavity was cleared of all clots and debris.

The uterine incision and the pelvic cavity were reinspected and excellent hemostasis was noted overall. The fascial incision was reapproximated with #0 Vicryl in a running fashion x2. Following that, the skin was reapproximated with staples. The instrument, needle, and sponge counts were correct x2.

Ectopic Pregnancy Removal and Salpingectomy Sample Report

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OPERATION:  Primary low segment transverse cesarean section.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed on the table in supine position, and after adequate epidural anesthesia, she was prepped and draped in the usual sterile fashion. A Pfannenstiel incision was made with a clean scalpel.  The incision was taken down the fascial layer with a clean second knife.  The fascial layer was incised transversely to the full length of the primary incision.  The underlying muscle bellies were dissected with blunt and sharp dissection.  The muscle belly was split in the midline.  The peritoneum was then grasped between 2 Kelly clamps and elevated.  After ensuring no adherent bowel or bladder, the peritoneum was nicked between clamps.  The abdominal cavity was thus entered.  The bladder flap was formed with blunt and sharp dissection and then the uterus was scored in the lower uterine segment in transverse fashion, and the incision was enlarged in elliptical fashion with bandage scissors.  The infant was found to be in face presentation with nuchal cord x1.  Mouth and nose were suctioned prior to delivery of rest of the body.  The cord was slipped over the shoulders and then the infant was delivered.  It was a living female with Apgars of 8 and 9.  There was meconium, but it was not thick.  Cord pH was 7.30.  The cord was doubly clamped, cut between the clamps, and the infant was handed away to the pediatrician.  Cord bloods were taken.

The placenta was then manually separated.  The edges of the uterine incision were then reapproximated with continuous running suture of #1 chromic catgut.  The second imbricating layer was also sewn using #1 chromic catgut.  Good hemostasis was noted.  The abdomen was cleaned of blood and clots.  Tubes and ovaries were inspected and found to be normal.  Then, the abdomen was closed in layers after correct sponge, needle, and instrument count.  The peritoneum was closed with continuous running suture of 0 chromic catgut.  The muscle bellies closed with interrupted sutures of 0 chromic catgut.  The fascia was closed with 2 continuous running sutures of 0 Vicryl beginning at either angle of the incision intermittently overlapping the midline.  The subcutaneous tissue was closed with continuous running suture of 3-0 plain catgut, and the skin was closed with surgical staples.  A sterile pressure dressing was applied.  Sponge, needle, and instrument counts were correct at the end of the procedure.

Pediatric Discharge Summary Samples #1                  

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OPERATION PERFORMED:  Repeat low transverse cesarean section via Pfannenstiel.

DETAILS OF OPERATION:  The patient was taken to the operating room where spinal anesthesia was found to be adequate.  She was then prepared and draped in the normal sterile fashion in the dorsal supine position with a leftward tilt.  A Pfannenstiel skin incision was then made with a scalpel and carried through to the underlying layer of fascia with the Bovie.  The fascia was then incised in the midline.  The incision was extended laterally with the Mayo scissors.  The inferior aspect of the fascial incision was grasped with the Kocher clamps, elevated, and the underlying rectus dissected off bluntly.  Attention was turned to the superior aspect of this incision, which in a similar fashion was grasped, tented up with the Kocher clamps, and rectus muscles dissected off bluntly.  The rectus muscles were then separated in the midline.  Peritoneum was identified, tented up, and entered sharply with the Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was then inserted and the vesicouterine peritoneum was identified, grasped with the pickups, and entered sharply with the Metzenbaum scissors.  This incision was then extended laterally and a bladder flap was created digitally.  The bladder blade was then inserted, and the lower uterine segment was incised in a transverse fashion with a scalpel.  The uterine incision was then extended laterally with the bandage scissors.  The bladder blade was removed, and the infant’s head was delivered atraumatically.  The nose and mouth were suctioned with bulb and the cord was clamped and cut.  The infant was handed off to the waiting pediatricians.  The placenta was then removed manually.  The uterus was cleared of all clots and debris.  The uterine incision was repaired with #0 Monocryl in a running locked fashion.  The peritoneum and muscles were closed with #2-0 Monocryl.  The fascia was reapproximated with #0 Vicryl in a running fashion, and the skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in stable condition.

Neonatal / Infant Discharge Summary Sample             

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OPERATION:  Total vaginal hysterectomy with bilateral salpingo-oophorectomy.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and satisfactory general anesthesia was obtained.  She was draped and prepped in the usual sterile fashion.  A weighted speculum was placed in the posterior vaginal wall and the right-angle retractor used to visualize the cervix.  The cervix was grasped across the anterior lip with a single-toothed tenaculum and circumferentially infiltrated with 1% Xylocaine with epinephrine at this time.  The cervix was circumferentially excised with the scalpel.  The vaginal mucosa was dissected superiorly with sharp dissection.  The anterior peritoneal reflection was identified, and it was entered with Metzenbaum scissors.  A posterior colpotomy was made through the cul-de-sac space.  The posterior peritoneum was identified in similar fashion and Metzenbaum scissors were used to enter the cul-de-sac.

At this time, a weighted speculum was placed, advanced posteriorly into the cul-de-sac.  At this time, the left and right uterosacral ligaments were isolated and ligated with 0 Vicryl. The LigaSure device was then used in a serial fashion up through the cardinal ligaments bilaterally.  Finally, the uterine arteries were cross-clamped, cut, and ligated with the LigaSure device.  LigaSure device was then used up through the broad ligaments superiorly and finally the uterus was rotated posteriorly.  The left and right tubes were then cross-clamped and ligated with LigaSure device.  The uterus was excised and submitted for pathologic evaluation.

At this time, Babcock clamps were used to grasp the left and right ovaries, and they were removed per the patient's request.  Curved Zeppelin clamps were placed across the infundibulopelvic ligaments bilaterally and curved scissors were used to excise the specimen from the Zeppelin clamp.  The pedicles were doubly ligated bilaterally with 0 Vicryl and hemostasis noted to be achieved.  No other abnormalities were noted in the pelvic cavity.

At this time, instruments were removed from the patient's abdominopelvic cavity.  Vaginal cuff closure and peritoneum were incorporated into one layer with 0 Vicryl suture in a continuous running interlocking fashion.  Hemostasis was noted to be achieved.  Foley catheter was then placed yielding clear amber urine. A vaginal packing with Premarin cream was placed to provide support during the healing process.  The patient tolerated the procedure well and was taken to the recovery room in a stable condition.  Sponge and needle counts were correct x3.

Delivery Note Transcribed Sample Report

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OPERATION:  Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room where she was laid in the supine position.  After adequate general anesthesia and endotracheal intubation had been obtained, the patient was placed in the lithotomy position.  Foley catheter was placed.  The patient was placed back in the supine position.  The abdomen was then prepped and draped using the usual sterile technique. 

A Pfannenstiel-type skin incision was made.  The abdomen was opened in layers.  Upon entering the peritoneal cavity, the uterus was held with traction using 2 large Kelly clamps.  The round ligament on the right side was clamped, cut, and suture ligated with 0 Vicryl suture ligature.  This procedure was then repeated on the opposite side.  The infundibulopelvic ligament on the right side was clamped, cut, and suture ligated with 0 Vicryl suture ligature, and the procedure was repeated on the opposite side.  The uterine artery and blood vessels were then skeletonized, clamped, cut, and suture ligated with 0 Vicryl suture ligature bilaterally.  The cardinal ligament was then clamped, cut, and suture ligated with 0 Vicryl suture ligature in 2 separate bites bilaterally.

The cervix was then whirled off of the vagina.  The specimen including the uterus, cervix, and both tubes and ovaries were handed to the circulating nurse.  A figure-of-eight suture ligature was placed at each angle of the vagina to incorporate the cardinal ligament for support.  The vaginal cuff was then closed with a 0 Vicryl suture ligature in a continuous fashion locking every stitch for hemostasis.  The excess blood was cleaned from the peritoneal cavity.  The peritoneum was then irrigated using normal saline.  No bleeding was noted.  The lap and instrument counts were noted to be correct, and the fascia was closed with 0 Vicryl in continuous fashion locking every stitch, and the skin was closed with skin clips and a sterile dressing was applied.  The patient tolerated the procedure well and left the operating room in satisfactory condition.

More Ob/Gyn Sample Reports

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OPERATION:  Supracervical hysterectomy.

OPERATION IN DETAIL:  The patient was placed in the dorsal supine position after an adequate level of general anesthesia was obtained and after appropriate informed consent had been obtained.  The Foley was draining clear urine from the bladder.  After the patient was prepped and draped in the usual sterile manner, a Pfannenstiel incision was made at the level of her previous C-section scar.  Subcutaneous tissue was incised until the level of the rectus fascia was reached.  A nick was made in the fascia.  This was extended the length of the incision using Mayo scissors.  The recti muscles were separated.  The peritoneum tented between two Kelly clamps, nicked with the knife and the incision extended vertically up and down taking care to avoid the bladder at the lower pole.  The talcum was washed off the gloves and the liver was palpated and was felt to be smooth.  The bowels grossly appeared normal.  The uterus was globular and uniformly enlarged with some intramural fibroids and some seedling fibroids on the surface of the uterus.  The ovaries were normal for age and so were the tubes.  The fundus was delivered out of the incision.

The right round ligament was clamped with two Kelly clamps, cut with Metzenbaum scissors and suture ligated with #0 Vicryl.  The anterior leaf of the broad ligament was cut using Metzenbaum scissors.  The bladder that was adherent to the anterior aspect of the uterus was gently dissected using sharp and blunt dissection and it was gently pushed down with the sponge on a stick.  Two fingers were inserted through the posterior leaf of the right broad ligament.  The tissue was cut with Metzenbaum scissors and it was clamped using a straight Heaney clamp.  Another clamp was placed medial to this.  It was cut with Metzenbaum scissors.  Sutures transfixed x2 using #0 Vicryl.  The right uterine artery was then skeletonized, clamped at the level of the cervical os using a curved Heaney clamp.  Another clamp was placed medial to this.  It was cut with the Metzenbaum scissors and suture transfixed x2 using #0 Vicryl.  Similar procedure was done on the opposite side.

A superficial incision was made on the anterior pubovesical cervical fascia using the knife and using the sponge on the stick, the tissue was further advanced, trying to avoid trauma to the bladder and ureters.  On the right cardinal ligament, a small bite of tissue was taken using straight Heaney clamp.  It was cut with the knife and suture transfixed using #0 Vicryl.  Since the patient had wished to preserve her cervix, knife was taken and the fundus was amputated from the cervix and handed over to the scrub nurse to be sent to the lab.  The cervix was approximated using interrupted sutures of #0 Vicryl followed by continuous interlocking sutures for hemostasis.  Adequate hemostasis was assured.  Ureters were seen peristalsing on either side and indigo carmine IV was given, blue colored urine was seen draining through the Foley. 

Once appropriate hemostasis had been achieved and the lap and instruments counts were reported as correct, the parietal peritoneum was approximated using #0 Vicryl continuous stitch, followed by approximation of fascia using Vicryl #1 continuous stitch in two segments.  The skin was approximated with #4-0 Vicryl subcuticular stitch.  The patient tolerated the procedure well and returned to the recovery room in good condition with Foley draining blue-colored urine.


OPERATION:

1.  Laparoscopic tubal interruption by way of Falope rings.
2.  Aspiration of hemorrhagic left ovarian cyst.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the dorsal supine position.  She was then placed under general anesthesia and intubated.  She was then placed in the dorsal lithotomy position and was examined under anesthesia with notation of a normal size uterus.  No adnexal masses were appreciated.  The bladder had been previously drained of approximately 50 cc of urine.  Graves speculum was introduced into the vagina exposing the cervix, which was then grasped on its posterior lip with a single-toothed tenaculum and a Hulka tenaculum was subsequently advanced.  All instruments were then removed.

Attention was then turned to the abdomen, and with the patient in a slight degree of Trendelenburg, an infraumbilical incision was then performed through which the Veress needle was advanced.  Once the entry was confirmed, the abdomen, the 5 mm trocar was then advanced allowing further visualization of the pelvis without any gross abnormalities noted.  The second puncture site was then placed approximately 2 fingerbreadths above the symphysis pubis through which a 10 mm trocar was advanced.  Through this, the laparoscopic probe was advanced, and with the uterus anteflexed, the following findings were noted.  Primarily, a normal-appearing pelvis with the exception of a 5 to 6 cm left hemorrhagic cyst and a small peritubal cyst on the same side.  The appendix could not be visualized.  All other findings were within normal limits.

With these findings noted, we proceeded to perform the tubal interruption with the Falope rings.  The Falope ring applicator was subsequently advanced on either side, rings were placed without difficulty, and photographs were obtained.  With these findings noted, using a unipolar small spatula a small hole was subsequently placed in the cyst, subsequently allowing drainage of the cyst contents, being noted as blood tinged, relatively thin fluid.  This fluid was subsequently aspirated from the cul-de-sac and sent to pathology for cytology and ovary was otherwise within normal limits.

With these findings noted, all instruments were then removed, after the abdomen was deflated, under direct visualization, and the skin edges were approximated using 2-0 Vicryl to approximate the fascia and 4-0 Prolene to approximate the skin in a subcuticular fashion.  Steri-Strip was placed across the incision.  Finally, the Hulka tenaculum was removed and hemostasis was noted.  This marked the end of the procedure.  The patient was returned to the dorsal supine position, subsequently extubated, and taken to the recovery room in stable condition.

Infant / Child Physical Examination Section Words     

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OPERATION:  Dilatation and curettage, diagnostic hysteroscopy.

DETAILS OF OPERATION:  The patient was taken to the operating room where general anesthesia was given.  She was then prepped and draped in the usual sterile fashion in the dorsal lithotomy position.  Examination under anesthesia was then performed with the above findings noted.  A weighted speculum was placed in the posterior fornix, and the anterior lip of the cervix was grasped with a single-tooth tenaculum.  At this time, gentle sounding of the uterus revealed the uterus to be sounded to 10 cm and then aggressive dilatation of this very stenotic cervix was made in order to allow the insertion of a diagnostic hysteroscope.  A 30-degree diagnostic hysteroscope was then inserted using lactated Ringers as the descending medium, and the hysteroscope was gently advanced to the uterine fundus.  Cavity initially was very difficult to visualize secondary to a lot of endometrium and a lot of tissue that was noted.  So, at this time, the hysteroscope was removed, and dilation and curettage was performed.  Once the tissue was cleared from the cavity, the hysteroscope was then reintroduced in order to clearly examine the cavity in order to ensure that there was no evidence any submucous myomas or any polyps that were noted.  None of the above were noted.  At this time, the hysteroscope was then removed.  The curette was then reinserted just to ensure that all tissue had been removed, and endometrial curettings were sent to pathology.  Also, of note is that prior to the insertion of the hysteroscope, endocervical curettage was performed, and those curettings were also sent to pathology.  Sponge, lap, and needle counts were correct x2.  At this time, all instruments were removed.  Hemostasis was assured, and the patient was placed in the supine position and awoken from general anesthesia.

Additional Ob/Gyn procedure terms encountered        

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OPERATIONS:

1.  Laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.
2.  Uterosacral colposuspension.
3.  Laparoscopic paravaginal defect repair.
4.  Tension-free vaginal tape urethropexy.
5.  Posterior colporrhaphy.
6.  Perineorrhaphy.
7.  Cystoscopy.

DESCRIPTION OF OPERATION:  After induction of satisfactory general endotracheal anesthesia, the patient was placed in lithotomy position in low stirrups.  The abdomen, vulva and vagina were prepped and draped in a sterile manner.  Exam under anesthesia revealed a small, freely mobile uterus which was nearly at the introitus at rest.  A third-degree cystocele with urethrocele was noted with loss of lateral support.  Significant rectocele with enterocele was noted with loss of rugae in the upper third of the vagina.  The perineal body was noted to be relatively thin.  Hulka tenaculum was placed in the cervix, and a Foley catheter was placed in the bladder.  The umbilical region was infiltrated with 0.5% Marcaine with epinephrine.  A 5 mm Optiview trocar and cannula were inserted under direct visualization.  Trocars were removed and the laparoscope was inserted and connected to the video camera light source.  A 10 mm trocar and cannula were placed in the right lower quadrant under direct visualization after infiltration of 0.5% Marcaine with epinephrine.  A 5 mm trocar and cannula were placed in the left lower quadrant under direct visualization after infiltration of 0.5% Marcaine with epinephrine.  The pelvic contents were visualized and noted a small uterus, deep cul-de-sac, normal bilateral fallopian tubes and ovaries, normal appendix, and both ureters were identified crossing the pelvic brim and pelvic sidewall.  The left round ligament was coagulated and transected using LCS Harmonic device.  The left broad ligament was opened down to the level of the uterine artery and vein.  The left infundibulopelvic ligament was coagulated using LCS and then transected.  The right round ligament was coagulated and transected using LCS, and the right broad ligament was opened down to the level of the right uterine artery and vein.  The right infundibulopelvic ligament was coagulated and transected using LCS.  Peritoneum of the lower uterine segment was entered using LCS, and the bladder was dissected off the lower uterine segment using blunt dissection.  Careful inspection revealed complete hemostasis.

The patient was partially repositioned for vaginal portion of the procedure.  Hulka tenaculum was removed and a single-tooth tenaculum was placed in the cervix.  The cervix was infiltrated with dilute Pitressin.  Posterior colpotomy incision was made to enter the posterior cul-de-sac using Metzenbaum scissors.  First, the left and right uterosacral ligaments were clamped, divided and suture ligated using #0 Vicryl.  The mucosa of the anterior cervix was entered with a scalpel and the bladder was dissected off the cervix.  Careful dissection entered the anterior cul-de-sac.  The right and then left paracervical tissue was clamped, divided and suture ligated using #0 Vicryl.  The right and the left uterine artery and vein were clamped, divided and suture ligated using #0 Vicryl.  A small amount of remaining parametrial tissue was then clamped, divided and suture ligated using #0 Vicryl.  The cervix and uterus with attached adnexa were removed.  Careful inspection revealed complete hemostasis.  Tag sutures had been left on the remnants of the uterosacral ligaments.  The right uterosacral ligament tag was placed under traction to identify the remnants of the right uterosacral ligament.  A #0 PDS suture was placed to the proximal right uterosacral ligament and sutured to the anterior and posterior pelvic fascia beneath the vaginal cuff on the right side.  Identical process was performed on the left, although some difficulty was encountered in identifying and actually suturing through the attenuated left uterosacral ligament.  Both these sutures were tied to elevate the vaginal cuff.  The remaining vaginal cuff mucosa and anterior and posterior fascia were then closed in an interrupted manner using #2-0 Vicryl.  Careful inspection revealed complete hemostasis with good elevation of the vaginal cuff.  Paravaginal defect and rectocele remained.

The patient was partially repositioned for laparoscopic portion of the procedure.  Pneumoperitoneum was reobtained and careful examination revealed complete hemostasis.  The anterior abdominal wall peritoneum was entered between the obliterated umbilical artery remnants, at least 3 cm above the pubic symphysis.  Careful dissection was performed in the preperitoneal space to enter the space of Retzius.  With the assistant's fingers in the vagina, the left and right vaginal margins were identified as well as the arcus tendineus fascia pelvis bilaterally.  Two interrupted sutures of #2-0 Ethibond were placed between the left vaginal margin including the endopelvic fascia and the left arcus tendineus fascia pelvis.  These were tied to elevate the left side of the vagina and reduce the paravaginal defect.  Identical process was performed on the right placing 3 sutures between the pubocervical fascia and lateral vagina to the right arcus tendineus fascia pelvis.  The space of Retzius was then irrigated and complete hemostasis was noted.  The anterior peritoneal defect was then closed in a continuous manner using #2-0 Vicryl.  The instruments were removed and the gas was allowed to escape.  The fascia of the right lower quadrant incision was closed in a figure-of-eight manner using #2-0 Vicryl.  All the 3 skin incisions were closed in a subcuticular manner using #4-0 Vicryl.

The patient was partially repositioned for TVT procedure.  The anterior vaginal mucosa beneath the midurethra was infiltrated with 0.5% Marcaine with epinephrine.  A vertical midline incision was made beneath the midurethra, nearly 1.5 cm length.  Careful submucosal dissection was performed to identify the endopelvic fascia.  TVT trocar was then placed to the right of the urethra, into the space of Retzius, across the back of the pubis to exit through the skin, approximately 2.5 cm to the right of midline.  Identical process was performed to the left of the urethra without difficulty.  Both trocars were left in place.  Foley catheter was removed and cystoscope was inserted.  Intravenous indigo carmine dye was given.  Complete evaluation of the bladder mucosa was performed noting no lacerations, dimpling, tears, bleeding or trocar penetration of the mucosa or muscular layers.  Both ureteral orifices were identified.  Prompt excretion of blue-tinged urine from both ureteral orifices was noted.  Cystoscope was withdrawn.  Both trocars were probed through the abdominal skin to place the vaginal tape beneath the midurethra.  Careful tensioning of the tape was performed using Mayo scissors placed vertically beneath the urethra to allow proper tensioning.  Sheaths were removed from both mesh tapes.  Tapes were pinned with the skin line and the skin was closed using #4-0 Vicryl.  The vaginal mucosa was closed using #2-0 chromic gut suture.  A moderate amount of bleeding from the suburethral tissue was noted.

The perineum and posterior vaginal midline were infiltrated with 0.5% Marcaine with epinephrine.  A small diamond-shaped wedge of mucosa was removed from the posterior introitus, and then posterior midline submucosal dissection was performed up to the upper vagina.  Careful blunt and sharp dissection was performed between the fascia and the vaginal mucosa up to the vaginal cuff.  A wide midline defect of fascia was noted.  This was closed in an interrupted manner using #2-0 PDS.  Upper margin of this defect was then sutured to the vaginal cuff using PDS to complete the posterior repair.  The perineum was rebuilt using interrupted #2-0 Vicryl sutures.  The vaginal mucosa was then closed in a continuous manner using #2-0 chromic gut suture.  AVC cream was placed on the vaginal pack, which was inserted to apply light pressure beneath the urethra.  Foley catheter was reinserted.  The patient was awakened in the operating room and taken to the recovery room in satisfactory condition.




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