text: PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,PROCEDURE PERFORMED:,1.  Laparotomy.,2.  Myomectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS:  ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium.  Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position.  After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife.  This was carried through the underlying layer of fascia with a second knife.  The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly.  It was then dissected in the middle with the Mayo scissors.  The inferior aspect of this incision was addressed in a similar manner.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly.  Next, the uterus was grasped bluntly and removed from the abdomen.  The fundal fibroid was identified.  It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels.  15 cc was injected.  Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen.  The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger.  The fibroid was easily and bluntly dissected out.  It was also grasped with Lahey clamp to prevent traction.  Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse.  The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed.  At this point, several smaller fibroids were noticed along the endometrial surface of the uterus.  Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size.  These were also handed to the scrub tech.  Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch.  The uterus was seen to be completely hemostatic after closure.  Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline.  The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed.  Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline.  Then the fascia was closed with #0 Vicryl in a running fashion.  Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately.  After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.surgery, enlarged fibroid uterus, blood loss anemia, laparotomy, myomectomy, metzenbaum scissors, uterus, fibroid, rectus, fascia, scissors, fashion, clamps, enlarged, incision, bluntly, 