EXPLAIN: SEVERE DYSMENORRHEA

CONTENT: LAPAROSCOPIC PRESACRAL NEURECTOMY

Clinical Information:

Major symptoms and signs:

Abnormal uterine bleeding: [[Menorrhagia, Hypomenorrhea, Persistent spotting, Irregular bleeding]]

Pain: [[Dysmenorrhea, Chronic pelvic pain, Flank soreness, Low back pain, with radiation to leg]]

Severity of pain: [[analgesics in vain, interrupt her daily work, ever been sent to ER for analgesics, analgesics needed and effective]]

Sonography:

Uterus: {{AVF, RVF}}, {{Normal size, There are/is _____ myomata measuring up to _____ cm, Adenomyosis measuring up to ______cm.}}

Right adnexa: {{Normal size, mass measuring up to ____ cm}}

Left adnexa: {{Normal size, mass measuring up to ____ cm]]

Operative Procedures:

Type of operation: Presacral neurectomy + Lysis of adhesion,

The patient was placed in the dorsal lithotomy position with both legs wrapped with elastic bandage. The uterine manipulator was inserted through the cervix and locked in place. The telescope was introduced through the umbilicus after establishing a pneumoperitoneum of 15 mmHg in pressure with Veress needle. And two other 5-mm accessory cannulas were placed through each lower quadrant. The adhesion tissues were removed, and the intestine, the omentum, and the peritoneum were separated and relocated at sites as normal anatomical structures.

Steep Trendelenburg position and tilting of the operating table to the left side are required to keep the bowel out of the operative field. The sacral promontory, ureters, and iliac vessels are identified. The peritoneum overlying the sacral promontory is elevated by smooth grasping forceps, a horizontal opening is made, and that extended cephalad to just below the aortic bifurcation. The common iliac arteries and veins; ureters; and midsacral arteries should be identified. The loose areolar tissue is excised as necessary to gain access to the plexus nerves. The superior hypogastric bundle is identified, grasped, and skeletonized as necessary. A segment of nerve tissue is excised. A wide portion of nerve between the two common iliac arteries laterally, bifurcation of aorta superiorly and sacral promontory inferiorly (triangle of Cote) are removed. The whole pelvis and operation sites were irrigated thoroughly to ensure the proper hemostasis.

The procedures ended with careful removal of the instruments and closure of the wounds. The patient stood the procedure well.

Operative Finding:

Uterus: {{AVF, RVF}}, {{Normal size, enlarged as GA ____ weeks size}}.

Right ovary: [[free, adhesion]] and [[grossly normal, solid mass measuring up to __ cm, cystic mass measuring up to __ cm, mass with mix component measuring up to __ cm]]

Left ovary: [[free, adhesion]] and [[grossly normal, solid mass measuring up to __ cm, cystic mass measuring up to __ cm, mass with mix component measuring up to __ cm]]

Right tubes: [[free, adhesion]] and [[grossly normal, s/p ATS, hydorsalpinx, __________]]

Left tubes: [[free, adhesion]] and [[grossly normal, s/p ATS, hydorsalpinx, __________]]

Cul-de-sac: [[free, membranous adhesion, partially obliterated, total obliteration, _____________]]

Adhesion: among/between [[uterus, left adnexa, right adnexa, colon, small intestine, pelvic side wall]]

Complication: [[Massive bleeding, Bladder injury, Ureter injury, Bowel injury, __________________ ]]

Pathology:

Dr:_______________________ Date:______________________