Case No.

: Major Scrub 2
Name of Student: Mary Edella Acob
Year and Section: III-I

Name of Patient: S. T. M. Age: 57 Sex: Female Civil Status: Married

Date of Admission: 9/30/19 Time Started/Ended: 1:43 PM – 4:20 PM
Date of Surgery: 10/1/19
Bed #: 3122 Hospital No.: 19-130000238091 Admissions No.: 19I00979

Surgeon: Dr. Jocelyn Mariano, MD

Assistant Surgeon: Dr. Raymundo, MD
Anesthesiologist: Dr. Milo, MD
Scrub Nurse: Chelsi Anne Y. Abolencia , RN
Circulating Nurse: Emy Grace M. Mangosing, RN

Chief Complaint: Post-menopausal bleeding / spotting

Rationale/Definition: Postmenopausal bleeding occurs in a woman’s vagina after she has
undergone menopause. Abnormal vaginal bleeding after menopause can be a
symptom of cervical, uterine, or endometrial cancer. Bleeding can occur in
postmenopausal women for several reasons. One of the reasons that is
manifested to the patient was thickened endometrium and multiple myoma showed
in her ultrasound. After menopause, you may have too much estrogen and too little
progesterone. As a result, the endometrium gets thicker and can bleed.

Pathophysiology:
Etiology:
Unknown
Predisposing factors:
Precipitating factors:
• Age (57 years old)
• Obesity
• Menopause

Increased estrogen

Proliferation of endometrial cells

Diagnostic test:
• Endometrial biopsy
• Transvaginal Thickening of uterine Signs and Symptoms:
lining • Bleeding or spotting
ultrasound
• Hysteroscopy
Periods of anovulation

Absence of Progesterone to
counteract Estrogen
activity
 Endometrium thickens further and
becomes highly vascularized

If not treated Treatment:

If treated
- Hysterectomy

overgrowth of unusual cells Decrease the risk

of cancer

Endometrial Cancer

Post-Op Diagnosis: Extra-fascial Hysterectomy with Bilateral Salpingo-Oophorectomy with

bilateral pelvic and paraaortic lymph node dissection, peritoneal fluid cytology
Rationale/Definition: Extra fascial technique permits removal of the intact uterine fundus and cervix,
leaving the parametrial soft tissues or a portion of the upper vagina. Additionally,
bilateral salpingo-oophorectomy is surgery to remove both ovaries and fallopian
tubes. There was a collected peritoneal fluid to examined for the presence of tumor
cells or malignant cells.

Surgical procedure: Extra fascial Hysterectomy with Bilateral Salpingo-Oophorectomy with bilateral
pelvic and paraaortic lymph node dissection
Definition: It is a surgery to remove the uterus and cervix. A bilateral salpingo-oophorectomy
is surgery to remove both of your ovaries and fallopian tubes. Extra fascial
technique permits removal of the intact uterine fundus and cervix, leaving the
parametrial soft tissues or a portion of the upper vagina. Extra fascial hysterectomy
can be accomplished through an abdominal incision, transvaginal, or by using a
combination of laparoscopic and transvaginal techniques. Dissection of bilateral
pelvic and paraaortic lymph node evaluates a major component of the surgical
staging procedure for several gynecologic malignancies, including endometrial
and ovarian carcinoma.
Indication: It is needed for the patient because the patient showed an endometrial thickening
and a histopathology of poorly differentiated malignant neoplasm. This procedure
prevents developing cancer in the lining of the uterus. The patient is already
menopause which also offered a removal of ovaries and fallopian tubes. As
mentioned earlier there is a malignant neoplasm that might contribute to worsening
the condition. The surgical and oncologic goals of the bilateral lymph node
dissection is to define the extent of disease and, thereby, to guide further
treatment.

Type of anesthesia: General and Local

Specific technique: Endotracheal and Subarachnoid / spinal block
Main anesthetic agent: Sevoflurane and Bupivacaine HCl
Mechanism of action:
Sevoflurane - Induces a reduction in junctional conductance by decreasing gap junction channel
opening times and increasing gap junction channel closing times. Sevoflurane also
activates calcium dependent ATPase in the sarcoplasmic reticulum by increasing the
fluidity of the lipid membrane. It also appears to bind the D subunit of ATP synthase and
NADH dehydogenase and binds to the GABA receptor, the large conductance
Ca2+ activated potassium channel, the glutamate receptor, and the glycine receptor.
Bupivacaine – It blocks the generation and the conduction of nerve impulses, presumably by increasing
the threshold for electrical excitation in the nerve, by slowing the propagation of the nerve
impulse, and by reducing the rate of rise of the action potential. It prevents depolarization
by binding to the intracellular portion of sodium channels and blocking sodium ion influx
into neurons. In general, the progression of anesthesia is related to the diameter,
myelination and conduction velocity of affected nerve fibers. The analgesic effects are
thought to potentially be due to its binding to the prostaglandin E2 receptors, subtype EP1
(PGE2EP1), which inhibits the production of prostaglandins, thereby reducing fever,
inflammation, and hyperalgesia.

Position: Supine
Equipment used for Positioning: Pillow, safety strap and grounding pad
Incision: Midline vertical incision carried down to peritoneum
Skin preparation: Abdomen down to suprapubic
Disinfectant used: Betadine and cutasept-F
Draping: Lap sheet, towel (4)

Sutures and Needles:

Tissue Layer Needle Name of Suture Suturing Technique
Used

• Skin • Cutting • Vicryl • Interrupted Suture

• Subcutaneous Fat • Round • Vicryl • Subcutaneous Suture
• Fascia • Round • PDS Plus • Deep Suture
• Muscle • Intestinal • Mersilk 3-0 • Interrupted Suture
• Peritoneum • Round • Vicryl OCT 1 • Continuous suture

Instruments:
Clamping Retracting Grasping Cutting Others

• Kelly fine • Malleable • Thumb • Knife • Bowl

• Peritoneal • Army Navy Forceps • Mayo • Kidney Basin
• Tonsil • Richardson • Tissue Straight • Medicine Cup
• Ochsner • Balfour Forceps • Mayo Curve • Cautery
Straight • Bladder • Russian • Metzenbaum • Needle
• Ochsner Retractor • De Bakey Holder
curve • Deaver • Adson • Suctions
• Kelly • Allis long and
Mayo short
• Babcock long
and short
• Sponge stick
• Towel clip
• Kocher