DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Low-grade squamous intraepithelial lesion of the cervix, chronic with insufficient endocervical cells on both Pap smear and colposcopic endocervical curettage.
POSTOPERATIVE DIAGNOSIS: Low-grade squamous intraepithelial lesion of the cervix, chronic with insufficient endocervical cells on both Pap smear and colposcopic endocervical curettage.
PROCEDURES PERFORMED: LEEP cervical cone biopsy and post LEEP endocervical curettage.
SURGEON: John Doe, MD
ANESTHESIA: Local.
FINDINGS: The patient has macroscopically normal-appearing cervix with no areas of decreased uptake of Lugol, severely stenotic os.
COMPLICATIONS: None.
SPECIMENS: Endocervical curettage and LEEP cone biopsy.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, and she was placed on the operating room table in the dorsal lithotomy position. The vagina and perineum were draped in the usual fashion. Using a bivalved speculum, the cervix was visualized and painted with Lugol solution. Using lidocaine with epinephrine on a spinal needle, the cervix was injected. The ectocervix was injected for local anesthesia.
Using the green loop, a flat cone biopsy was removed from the ectocervix surrounding the os. Using an os finder, the cervical os, after the LEEP was completed, was visualized and found and probed. Subsequent to that, using a Kevorkian curette, the endocervix was scraped. The scrapings were sent to pathology separately. Hemostasis was adequate. The base of the cone as well as the remainder of the ectocervix around the removed cone were ablated, and the patient was then taken to the same-day surgery from where she was discharged home in good condition having tolerated the procedure well. Hemostasis was adequate.
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DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Mild to moderate cervical dysplasia.
POSTOPERATIVE DIAGNOSIS: Mild to moderate cervical dysplasia.
PROCEDURES PERFORMED: Loop electrosurgical excision procedure, cervical cone biopsy.
DESCRIPTION OF PROCEDURE: The patient was taken to the outpatient department where in the low dorsal lithotomy position, her cervix was identified with a medium Graves speculum. Cervix was then copiously irrigated with Lugol’s solution and infiltrated with 4 mL of 1% lidocaine with epinephrine for anesthesia.
A LEEP cervical cone biopsy was performed in the usual fashion. The tissue was sent to pathology for histopathologic confirmation. Areas of bleeders were hemostatic with cautery. After hemostasis was confirmed, the instruments were removed from the vaginal vault. The patient was then placed in the supine position.
The patient tolerated the procedure well. There were no intraoperative complications. Estimated blood loss was less than 5 mL. The patient will return in two weeks for routine postoperative exam.
