text: PREOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,POSTOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,PROCEDURE PERFORMED:,  Exploratory laparotomy and right salpingectomy.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity.  Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS:  ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain.  The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate.  Evaluation in the emergency room reveals a second right ectopic pregnancy.  Her beta quant was found to be approximately 13,000.  The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity.  Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy.  The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery.  Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where general anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors.  The rectus muscles were dissected in the midline.  The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder.  At this time, the blood found in the abdomen was suctioned.  The bowel was packed with moist laparotomy sponge.  The right ectopic pregnancy was identified.  The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture.  Hemostasis was visualized.  At this time, the left tube and ovary were examined and were found to be normal in appearance.  The pelvis was cleared off clots and was copiously irrigated.  The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed.  The rectus muscles were reapproximated using 3-0 Vicryl.  The fascia was reapproximated with #0 Vicryl sutures.  The subcutaneous layer was closed with 3-0 plain gut.  The skin was closed with 4-0 Monocryl.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.obstetrics / gynecology, ectopic pregnancy, salpingectomy, exploratory laparotomy, fallopian tube, mayo scissors, rectus muscles, 