DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Cervical intraepithelial neoplasia.
POSTOPERATIVE DIAGNOSIS: Cervical intraepithelial neoplasia.
PROCEDURE PERFORMED: Cone biopsy and endocervical curetting. Biopsy at 6 o’clock and biopsy at 12 o’clock and endocervical curettings.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Approximately 50 mL.
PROCEDURE FINDINGS: Uterus was normal size and shape. Cervix is multiparous, small dimple appreciated at 12 o’clock, minimal amount of non-Lugol staining region between 4 and 6 o’clock noted initially and then investigation up the dimple at 12 o’clock noted to be non-Lugol uptake as well.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the operating table in supine position. After receiving adequate level of anesthesia, the patient was placed in dorsal lithotomy position. She was prepped and draped in sterile fashion with bladder catheter at 500 mL.
After anesthesia was performed with the above noted finding, weighted speculum was placed in the posterior aspect of the vagina. Sims retractor was placed in the entry passage of the vagina. Single-tooth tenaculum was used to grasp the anterior lip of the cervix. Stay sutures were placed at 3 and 9 o’clock with 2-0 Vicryl. Lugol solution was placed, and non-Lugol uptake regions were excised at 4 o’clock in cephalad fashion. Tag was placed at 6 o’clock on this lesion. Further investigation was performed at the dimple appreciated at 12 o’clock, opened and stained with Lugol, minimal portion noted to be non-Lugol uptake region. This was excised and sent to office at 12 o’clock specimen. Endocervical curetting was performed. Scant tissue was noted. Endocervix was sounded.
Hemostasis was obtained with 2-0 Vicryl in figure-of-eight and cautery was performed. Good hemostasis was appreciated. Stay sutures were excised. The patient was returned to supine position after that was visualized for 10 minutes without any bleeding. The patient was returned to supine position, anesthesia was reversed, and the patient was brought to recovery room in stable condition after tolerating the procedure well. Counts were correct. Hemostasis was noted.
