DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Menorrhagia.
POSTOPERATIVE DIAGNOSIS: Menorrhagia.
OPERATION PERFORMED: Diagnostic hysteroscopy with D&C and NovaSure ablation.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia by way of oral endotracheal tube intubation.
FLUIDS: 600 mL of crystalloid.
URINE OUTPUT: 200 mL.
FINDINGS: Proliferative-appearing endometrium with several large polypoid-like areas.
COMPLICATIONS: None.
SURGICAL COUNT: Correct.
SPECIMEN: Endocervical curettage and endometrial curettage to pathology.
DISPOSITION: To the recovery room in stable condition.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the dorsal supine position, wherein she was placed under general anesthesia and subsequently intubated. She was then placed in the dorsal lithotomy position. Subsequently, the bladder was drained of approximately 200 mL of clear urine. She was then prepped and draped in the usual sterile fashion and placed in a slight degree of Trendelenburg. The patient was examined under anesthesia with notation of a relatively normal anteverted uterus, smooth and mobile. There were no adnexal masses.
The speculum was then placed into the vagina, thereby exposing the cervix. It was grasped on its posterior lip with a single-tooth tenaculum. Endocervical canal was then assessed and measured at 3.5 to 4 cm. The uterus sounded to approximately 9.5 cm, thereby a cavity length of 6 cm. The cervical os was then serially dilated to a sufficient size to allow passage of the hysteroscope. The passage of hysteroscope and the cervical canal appeared relatively normal. However, in the endometrium, there were numerous polypoid-like projections. The ostia were visualized on either side. With these findings noted, the cervical os was then serially dilated to a sufficient size to allow passage of the NovaSure ablation. Again, the cavity length was set at 6 cm, and the width was noted at 4.6 cm. With these findings noted, the instrument was enabled. Once enabled, the procedure was begun. The NovaSure proceeded for approximately 66 seconds at a wattage of 145.
At the completion, the instrument was removed. The endometrial cavity was reinspected with notation of an adequate burn and a clear line of demarcation between the lower uterine segment and the cervix. With this noted, the patient tolerated the procedure well. The single-tooth tenaculum was removed. Hemostasis was achieved by pressure. The speculum was removed. The patient was subsequently returned to the dorsal supine position. Anesthesia was subsequently reversed. The patient was then extubated and taken to the recovery room in stable condition.
