DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Low-grade Pap smear with inadequate colposcopy.
2. History of abnormal Pap smears, status post LEEP in the past.
POSTOPERATIVE DIAGNOSES:
1. Low-grade Pap smear with inadequate colposcopy.
2. History of abnormal Pap smears, status post LEEP in the past.
OPERATION PERFORMED: Cold knife cone.
SURGEON: John Doe, MD
ANESTHESIA: Laryngeal mask induced.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: Minimal.
IV FLUIDS: 800 mL of crystalloid.
URINE OUTPUT: 20 mL.
SPECIMENS: A cone biopsy of the uterus and cervix.
OPERATIVE FINDINGS: A small area at the lower portion of the endocervix that was found to be nonstaining on Lugol examination.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where laryngeal mask anesthesia was induced without difficulty. The patient was placed in the dorsal supine position with legs in candy-cane stirrups. After the urethra was cleaned with Betadine, approximately 20 mL of urine was drained from the bladder. The patient was draped.
A weighted speculum was placed in the posterior vagina. A Deaver retractor was placed anteriorly. The anterior lip of the cervix was grasped with the single-tooth tenaculum. A 1-0 Vicryl was placed at 3 o’clock and 9 o’clock positions for stay sutures. Lugol solution was applied to the cervix. There was a small nonstaining area noted at the lower portion of the endocervix. A #11 blade was used to obtain a cone-shaped biopsy of the cervix. The cone biopsy was tagged at 12 o’clock with silk. Hemostasis was obtained at the cone bed with the Bovie. Small pieces of Gelfoam with Monsel were placed against the cone bed. The two stay sutures at 9 o’clock and 10 o’clock were tied together. Good hemostasis was noted.
All instruments were removed from the vagina. The single-tooth tenaculum site was hemostatic. All sponge, lap, needle, and instrument counts were correct x2. The patient tolerated the procedure well. The patient was taken to the PACU in stable condition.
