DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: A (XX)-year-old gravida 5, para 4, with a history of cervical dysplasia, severe, rule out carcinoma of the cervix.
POSTOPERATIVE DIAGNOSIS: A (XX)-year-old gravida 5, para 4, with a history of cervical dysplasia, severe, rule out carcinoma of the cervix.
PROCEDURE PERFORMED: Cold knife cone of the cervix and endocervical curettings.
SURGEON: John Doe, MD
ANESTHESIA: General.
IV FLUIDS: 700.
BLOOD LOSS: Less than 50.
URINE OUTPUT: None.
FINDINGS:
1. Decreased Lugol uptake around the cervical os.
2. No masses.
SPECIMENS:
1. The cold knife cone biopsy of the cervix with 12 o’clock marked with a suture.
2. Endocervical curettings.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was taken to the OR where general anesthesia was found to be adequate. She was prepped and draped in the usual sterile fashion. A weighted speculum was placed in the patient’s vagina. Then, we painted the cervix with Lugol solution with the findings noted above. We then grasped an Allis at the 3 o’clock and 9 o’clock cervical-vaginal junction and placed a stitch at this point, figure-of-eight with 0 Vicryl at the level of the cervical vessels to aid with hemostasis, and also to have some grasping of the cervix for the procedure.
We then used a #11 blade and we cut in a cone-like fashion around the cervix, obtaining the cold knife cone biopsy specimen intact. We passed it off the field and we marked it with a suture at 12 o’clock for pathologist boundaries and then we used Monsel and the Bovie to achieve hemostasis of the excisional bed. The endocervical curettings were obtained, and we then ran a 0 Vicryl stitch in a running locked fashion around the edges of the cervical conization for hemostasis.
Then, after achieving good hemostasis, we placed a piece of Surgicel to aid with hemostasis and then we packed the vagina with gauze packing, moistened with normal saline. Then, after assessing sponge and needle counts correct x2 and all instruments were accounted for, we then removed all instruments from the patient’s vagina. We cut the sutures and then the patient was awakened from anesthesia and taken to the recovery room in stable condition.
