DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Missed abortion at 9 weeks’ gestational age by dates, 6 weeks’ gestational age by ultrasound.
POSTOPERATIVE DIAGNOSIS: Missed abortion at 9 weeks’ gestational age by dates, 6 weeks’ gestational age by ultrasound.
OPERATION PERFORMED: Suction D and C.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
INTRAVENOUS FLUIDS: 300 mL lactated Ringer’s.
URINE OUTPUT: 400 mL.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CONDITION: Stable.
SPECIMEN: Products of conception.
OPERATIVE FINDINGS: Exam under anesthesia revealed normal external genitalia. The patient has a small mid position uterus. Cervix is soft, normal in appearance without lesions, 2.5 cm in diameter. Uterus was sounded to 7.5 cm. Cervix was dilated to #14 Hanks dilator and #6 flexible suction curette was used. Tenaculum sites were hemostatic at the end of the case.
DESCRIPTION OF OPERATION: After consents were signed, the patient was taken to the OR where general anesthesia was obtained without difficulty. The patient was placed in Yellofin stirrups and prepped and draped in the normal sterile fashion in dorsal lithotomy position. A time-out was performed for patient safety.
After the bladder was drained, a Graves speculum was used to visualize the cervix. The cervix was then grasped at the anterior lip with a single-tooth tenaculum. The uterus was then gently sounded to 7.5 cm. The cervix was then gently and progressively dilated to #14 Hanks dilator. A #6 flexible suction curette was then inserted into the uterine cavity and attached to the suction tubing. The suction device was then activated and the curette turned to clear the uterus of products of conception.
A sharp curettage of the uterine cavity was then performed until a gritty texture was felt on all the surfaces. The specimen was collected and sent to pathology. The instruments were then removed from the vagina, including the tenaculum. Ring forceps was briefly placed on the anterior lip to achieve hemostasis at the tenaculum site. The ring forceps was then removed along with the speculum. The patient tolerated the procedure well. Needle, lap, and instrument counts were correct x2. The patient was taken to the recovery room in good condition.
