My surgery involved robotic segmental resection of the right tube with end-to-end anastomosis; right ovarian cystectomy; appendectomy; extensive ileal, sigmoidal, bilateral tubo-ovarian and uterine adhesiolysis (removal of adhesions); uterine suspension.
DESCRIPTION OF PROCEDURE: Under suitable anesthesia and in the semilithotomy position the patient was prepped and draped as customary. The abdomen appeared normal with no visible anomalies in the surface of the liver, gallbladder, stomach.
The ileum was adhesed to the pelvis as well as the sigmoid. Both tubes and ovaries were involved in dense thick adnexal masses fixed to the pelvic sidewall, back of the uterus, and cul-de-sac. An extensive adhesiolysis was carried out to return the anatomy back to normal, identifying a right ovarian cyst with subovarian adhesions, which was excised from the right ovary.
There was a large hemorrhagic necrotic mass that appeared to be originating from a ruptured midsegment of the right tube that was completely excised including the midsegment of the right tube. This mass was also involving the surface of the rectosigmoid, cul-de-sac, posterior uterine wall, and contralateral tube and ovary. An extensive bilateral tubo-ovarian adhesiolysis was performed, releasing the ovaries from the tubes and the ovaries from the parapelvic peritoneum. The cul-de-sac was also reconstructed, excising thick dense scar tissue from the anterior rectal wall and rectovaginal septum.
The bladder peritoneum was also thickened with scar tissue, and it was also excised. The uterus was in a markedly retroverted position and a uterine suspension was performed. The appendix was involved in the right conglomerate of the adnexal mass, and the base of the appendix was first divided with two Endoloops, transected, and then the tip of the appendix followed up to the area where the right tube appeared to have been ruptured. The appendix was then separated from the tube and exteriorized.
There was no gross evidence of endometriosis, although the thick dense scar tissue could have been secondary to old endometriosis or to the ruptured ectopic. A tuba1 dye study revealed no passage of the dye through the left tube, the fimbrial end of which could be identified. On the right side, the right tube was then anastomosed with four submucosal sutures of 5-0 Prolene. The pelvis was thoroughly irrigated with water.
Hemostasis was meticulously controlled with cautery. A methylene blue enema was then carried out and the integrity of the rectum confirmed. Once the hemostasis was excellent, a slurry of Seprafilm was spread throughout the entire pelvic area. Instruments were removed and incisions closed as customary. The patient tolerated the procedure well and was taken to the recovery room in good condition.