DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Moderate cervical dysplasia.
POSTOPERATIVE DIAGNOSIS: Moderate cervical dysplasia.
OPERATION PERFORMED: Loop electrosurgical excision procedure conization of the cervix.
SURGEON: John Doe, MD
ANESTHESIA: General by LMA.
ANESTHESIOLOGIST: Jane Doe, MD
COUNTS: Sponge and needle counts were announced as correct x2.
ESTIMATED BLOOD LOSS: 10 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gravida 2, para 2 woman, who had an atypical Pap smear that returned as ASCUS-H. Colposcopic examination revealed CIN 2 at the 12 o’clock position. The patient was therefore consented for a conization procedure.
DESCRIPTION OF OPERATION: After excellent general anesthesia, the patient was prepped and draped in a sterile fashion in the dorsal lithotomy position. No vaginal prep was done. A bivalve speculum was placed into the vaginal vault, and the cervix was bathed liberally with a 5% acetic acid solution. Acetowhite epithelium was noted to emanate. This was an adequate colposcopic examination. Dilute Lugol’s was then placed on the cervix with further delineation of the acetowhite epithelial areas.
Pitressin, 20 units in 40 mL of normal saline, was infiltrated locally into the cervix in a circumferential fashion for a total of 10 mL. The cervix was noted to blanch nicely. Using 100 watts of pure cut, the anterior lip of the ectocervix was removed in one pass. The posterior lip was then removed in one pass. A suture was placed at the 12 o’clock position. The endocervical specimen was then taken on one pass using 100 watts of pure cut. This was placed in a separate jar. Endocervical curettings were then done, and these were also placed in a third jar. The large ball electrode was then placed, and using 60 watts of pure coag, hemostasis was achieved in the cervical bed. Monsel’s solution was then placed on the cervical bed. There was good hemostasis. All instruments were removed.
Sponge and needle counts were correct x2. The patient awoke easily in the operating room and was taken to the recovery room in stable condition. The specimens were sent to pathology as follows: Jar #1 contained the ectocervical specimens with a suture at the 12 o’clock position. The anterior portion also was the larger piece. Therefore, the medium sized portion in the jar is the posterior lip, second endocervix, third endocervical curetting.
