DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. High-grade squamous intraepithelial lesion of the cervix.
2. Abnormal uterine bleeding.
POSTOPERATIVE DIAGNOSES:
1. High-grade squamous intraepithelial lesion of the cervix.
2. Abnormal uterine bleeding.
PROCEDURES PERFORMED:
1. Cold knife cone biopsy.
2. Endocervical curettage.
3. Hysteroscopy.
4. Dilatation and curettage.
SURGEON: John Doe, MD
ANESTHESIA: General.
PROCEDURE FINDINGS: Normal size uterus sounded to 8 cm. Smooth endometrial cavity with a thickened endometrium. No adnexal masses. A large amount of tissue was obtained upon curettage.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position on the operating table, where general anesthesia was administered. She was then placed in the dorsal lithotomy position where examination under anesthesia was performed. The patient was prepped and draped in the usual manner for surgery.
A weighted speculum was inserted into the vagina. The cervix was exposed with a Sims retractor, and the anterior lip of the cervix was grasped with a single-toothed tenaculum. Angle sutures of 0 Vicryl were placed at the 3 o’clock and 9 o’clock positions of the cervix in a figure-of-eight fashion. The cervix was infiltrated with diluted Pitressin solution 5 units and 100 mL of sterile saline. Approximately 20 mL of the solution was utilized. Cone biopsy was then excised with an 11 scalpel blade. After excision of the biopsy specimen, the biopsy bed was treated with cautery to assure hemostasis and then endocervical curettage was undertaken. The cervix was dilated up to a 15 Hanks dilator.
The hysteroscope was introduced, and the endometrial cavity was visualized using lactated Ringer’s as a distending medium. There were no polyps or fibroids. The endometrium was somewhat polypoid and thickened in appearance. Following withdrawal of the scope, an endometrial curettage was undertaken with a medium size sharp curettage. Following curettage, the cervix was again inspected for hemostasis and treated again with cautery. The procedure was then terminated.
All instruments were removed. The patient was returned to the supine position. The patient was awakened from anesthesia without any difficulty and transferred to the recovery room in good condition. The patient tolerated the procedure well.
