OB Tubal Note


Date of Birth:

Date of surgery:

Pre-op Diagnosis:  A _ years old female G2 P2002 scheduled for bilateral tubal ligation

Post-Op Diagnosis: A _ years old female G2 P2002 status post bilateral tubal ligation

Procedure Performed: Mini-laparotomy bilateral tubal ligation

Surgeon: _____ M.D

Attending Physician:  Bryan H Clardy, MD

Anesthesia:  General Anesthesia

Findings: Normal Anatomy and fallopian tubes bilaterally

Estimated Blood Loss:  Minimal

Complications:   None

Description of procedure:  Upon signing informed consent and discussing the risks, benefits and alternative treatments, the pt agreed to have a tubal ligation. The pt was taken to the OR where she was placed in a horizontal position. Abdomen was prepped and drapped. Anesthesia was initiated and after it was noted to be adequate, Marcaine 10ml was used prior to making an incision. A 4 cm subumbilical incision was made with the scaple. the fascial incision was then grasped with the kocher clamps, elevated and sharply and bluntly dissected. The abdomenal cavity was then entered bluntly. Two Army-Navy retractors were put into place and Babcock retractor was used to grasp the left fallopian tube and then re-grasped with the Babcock's and followed to the fimbriated end. The fallopian tube was caught and the edges were then cauterized, adequate hemostasis was noted. This tube was placed back in its anatomic position.

The right fallopian tube was grasped, followed to its fimbriated end and then re-grasped with the Babcock and the upper portion was sharply incised and the cut edge re-charaterized with adequate hemostasis and this was placed back into the anatomic position. The peritoneum as well as fascia were re-approximated with a 4-0 Vicryl and the skin edges were re-approximated  with 4-0 Vicryl as well in a subcuticular stitch. Pressure dressings were applied.  Sterile dressing was applied. Instrument count, needle count, and sponge count were all correct and the patient was taken to the recovery room in stable condition.