DATE OF SERVICE: MM/DD/YYYY

SUBJECTIVE: The patient is a (XX)-year-old nulliparous woman with LMP of MM/DD/YYYY, who came in for insertion of a ParaGard intrauterine device. We saw the patient at the end of January for an annual exam. Her Pap smear is still pending and her Gen-Probe was negative. The patient had been on birth control pills, but she gave a history of migraine headaches with visual symptoms, and we thought it best that she consider alternative contraception. The patient is interested in having a ParaGard intrauterine device.

The patient reviewed the consent form and we answered all her questions. The risks of the procedure were discussed including, but not limited to, bleeding, infection, and uterine perforation. The patient is aware that the highest risk of infection is in the first three months and that the intrauterine device is effective for 10 years but could be removed at any time.

OBJECTIVE: The patient is a healthy-appearing (XX)-year-old. Height 5 feet 7 inches, weight 168 pounds, blood pressure 120/70, pain score 2 for her headache.

PROCEDURE DETAILS: The patient was placed in the lithotomy position. A bimanual examination was done. The uterus was anteverted, mobile, and normal size. A speculum was placed in the vagina and the cervix swabbed with Betadine. Under sterile technique, the anterior lip of the cervix was grasped with a single-toothed tenaculum. The cervical os easily dilated to #10 Pratt dilator. The uterus sounded 3 inches. The ParaGard intrauterine device was inserted without difficulty and the strings were trimmed. The tenaculum was removed from the cervix and the speculum removed from the vagina. The patient tolerated the procedure well.

ASSESSMENT: Successful insertion of ParaGard intrauterine device.

PLAN: The patient was advised to check for the IUD string after every menses or at least after a heavy menses. If she is having no problem with the intrauterine device, she will be due for a visit next January.

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PREOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 36-4/7 weeks’ gestational age.
2.  Spontaneous rupture of membranes.
3.  Previous cesarean section x2.

POSTOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 36-4/7 weeks’ gestational age.
2.  Spontaneous rupture of membranes.
3.  Previous cesarean section x2.
4.  Severe adhesive disease.

SURGEON:  John Doe, MD

PROCEDURE PERFORMED:  Repeat low transverse cesarean section.

FINDINGS:  Septate uterus with separated cornua and uterus markedly enlarged, also viable male infant with Apgars of 9 and 9, present within uterine cavity.

DRAINS:  Foley to gravity.

ESTIMATED BLOOD LOSS:  1350 mL.

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was brought in for repeat low transverse cesarean section. Spinal anesthesia was obtained to an appropriate level. The patient was then prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made and carried down sharply to the fascia. The fascia was incised and dissected superiorly to the level of the umbilicus and inferiorly to the pubic bone. The rectus muscles were separated in the midline using both blunt and sharp dissection along with Bovie cautery. There was marked adhesive disease in the midline, and there was a large amount of scar tissue that required dissection to separate the rectus muscles.

A Pfannenstiel skin incision was made and carried down sharply to the fascia. The fascia was incised and dissected superiorly to the level of the umbilicus and inferiorly to the pubic bone. The rectus muscles were separated in the midline using both blunt and sharp dissection along with Bovie cautery. There was marked adhesive disease in the midline, and there was a large amount of scar tissue that required dissection to separate the rectus muscles.

Once the abdominal cavity was reached, there was marked adhesive disease between the abdominal wall and the anterior surface of the uterus. These adhesions were dissected off the anterior surface of the uterus using sharp dissection using Metzenbaum scissors. A bladder flap was created by further dissecting the scar tissue away from the lower uterine segment, and a bladder blade was placed.

A low transverse incision was then made and a viable male infant with Apgars of 9 and 9 was delivered atraumatically. The mouth and nose suctioned. The cord was clamped and cut. The infant was handed to the awaiting pediatrician. The placenta was delivered manually after much effort and removed in pieces. The uterus was markedly enlarged, almost double the size of an ordinary post-delivery uterine size, with a septation by the cornua separating the cornua. The placenta straddled the septation extending into both cornua and had to be removed manually in pieces with much difficulty.

The uterus was unable to be exteriorized, and once the placental fragments were removed, the low transverse incision was reapproximated using 0 chromic in a running locking fashion. Several figure-of-eight 0 chromic sutures were then placed for hemostasis. The low transverse incision was found to be hemostatic and the paracolic gutters were then cleared of blood clots. The low transverse incision was then covered with

The low transverse incision was then covered with Surgicel to help provide additional hemostasis. The rectus muscles were then reapproximated in the midline using three 0 chromic figure-of-eight sutures. The fascia was then reapproximated using 0 Vicryl in a running locking fashion.

Before finishing closing the fascia, there was a large amount of pooling of what at first was thought to be rundown bleeding, and it was decided to re-enter the abdominal cavity to ensure hemostasis throughout, so the suture within the fascia and the rectus muscles were removed and the low transverse incision within the uterus reinspected and again found to be hemostatic, except for one edge where an additional 2-0 chromic figure-of-eight suture was placed, allowing for hemostasis.

All the other wound edges as well as the bladder flap and the paracolic gutters were reinspected and found to be hemostatic. The rectus muscles were reapproximated using 3 U stitches of 0 chromic. The fascia was then reapproximated using 0 Vicryl in a running, nonlocking fashion. The subcutaneous tissues were irrigated. Bovie cautery was used for hemostasis. Three 0 catgut interrupted sutures were placed in the subcutaneous fatty tissue. The skin was then closed with staples, and a pressure bandage was applied. Once reentering the abdominal cavity, the patient was experiencing increased sensation with

The skin was then closed with staples, and a pressure bandage was applied. Once reentering the abdominal cavity, the patient was experiencing increased sensation with remainder of the period, and the patient was then placed under general anesthesia via face mask for additional analgesia and sedation. Once the procedure was completed, the patient was awakened and then brought to the recovery room in stable condition.

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DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.

POSTOPERATIVE DIAGNOSIS: Left ectopic pregnancy and cerclage in place.

OPERATION PERFORMED: Laparoscopic left salpingectomy and cervical exam under anesthesia.

SURGEON: John Doe, MD

ASSISTANT: None.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 600 mL with 550 mL of hemoperitoneum.

SPECIMENS: Left tube.

COMPLICATIONS: None apparent.

CONDITION: Stable to recovery room.

OPERATIVE FINDINGS:
1. Actively bleeding left ectopic pregnancy with 550 mL of hemoperitoneum in the abdomen
2. Surgical absence of the right tube.
3. Normal-appearing ovaries bilaterally.
4. Uterus adhesed to the bladder in the anterior abdominal wall.
5. Omental adhesions to the anterior abdominal wall.
6. Normal-appearing appendix and gallbladder.
7. Multiple cervical divots indicative of prior cerclage placement but no visible cerclage due to cervical mucosa.

DESCRIPTION OF OPERATION: After informed consent, the patient was brought to the operating room and placed supine on the operating table for laparoscopic left salpingectomy and cervical exam under anesthesia. General endotracheal anesthesia was then administered by the anesthesiologist. The patient was then placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion for an abdominal and vaginal procedure. A Foley catheter was placed into the bladder.

A Graves speculum was placed into the vagina and the cervix was carefully examined and manipulated around. There could be seen several divots in the cervix, indicative of where the cervix had been pierced during cerclage placement. However, even though the patient reported a pulling or pinching sensation, especially during intercourse, no visible portion of the cerclage could be seen protruding through the cervical mucosa. A small portion of what was possibly eroded Mersilene tape was grasped with ring forceps and removed, but the entire cerclage by no means was able to be retrieved.

A HUMI uterine manipulator was then placed into the uterus and this passed through easily and attention was returned to the abdomen. The umbilicus was infiltrated with 0.25% Marcaine and a stab incision was made through it. A 5 mm trocar containing a 5 mm 0-degree scope was placed into the abdomen under direct visualization. Pneumoperitoneum was then created with CO2 gas. Two other ports were then placed under direct visualization, a 10 mm in the left lower quadrant and a 5 mm in the right lower quadrant.

Systematic examination of the pelvis revealed the above findings. The omentum was adhesed to the anterior abdominal wall in the midline. This was taken down with the Harmonic scalpel. The right ovary appeared normal in configuration; although, it was somewhat adherent to the right pelvic sidewall. The left ovary and tube were encased in clot. The 10 mm suction was used to evacuate all clots; this amounted to 550 mL. The left tube contained an unruptured ectopic; although, the ectopic was actively bleeding bright red blood from the tubal end.

The tube was stabilized using a grasper and a Harmonic scalpel was used to dissect the tube away from the mesosalpinx and the ovary and also used to come across the tubal insertion into the uterus. The operative site was examined and found to be hemostatic.

A 10 mm EndoCatch was then placed into the abdomen and the left tube was placed in the EndoCatch and it was removed with a 10 mm port. The pelvis was then copiously irrigated and suctioned. The patient was taken out of Trendelenburg, and all the blood from the upper abdomen was allowed to run down into the pelvis and this was suctioned away as well. The pressure was dropped to 6 and all operative sites were examined and found to be hemostatic. The procedure was then terminated.

A Carter-Thomason CloseSure device was used to close the 10 mm fascial port with 0 Vicryl. All instruments were then removed from the patient’s abdomen and the gas was suctioned out of her abdomen. Her skin incisions were closed with 4-0 Vicryl in a buried fashion and Dermabond was applied to the incisions.

All sponge and instrument counts were correct x2 at the end of the procedure. The Foley catheter and HUMI uterine manipulator were also removed, and the patient was returned to the supine position and awoken from anesthesia. The patient did tolerate the procedure well. She was transferred to the recovery room with vital signs stable.

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PREOPERATIVE DIAGNOSES:
1.  Left adnexal mass.
2.  Pelvic pain.

POSTOPERATIVE DIAGNOSES:
1.  Left adnexal mass.
2.  Pelvic pain.
3.  Intestinal adhesions.
4.  Left hydrosalpinx with left cystadenoma.

OPERATION PERFORMED:
1.  Laparoscopic lysis of tuboovarian adhesions.
2.  Laparoscopic enterolysis.
3.  Laparoscopic left salpingo-oophorectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General via endotracheal tube.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

COMPLICATIONS:  None.

SPECIMENS:  Fallopian tube and ovary.

OPERATIVE FINDINGS:  There were extensive adhesions over the bowel and omentum to the anterior abdominal wall, in the right lower quadrant, where the patient’s appendectomy site was. In addition, there was a large retroperitoneal mass arising from the left ovary into the left broad ligament measuring approximately 10.5 cm in greatest dimension. There was a left hydrosalpinx overlying this, and there were bilateral paratubal and paraovarian adhesions. The right ovary appeared normal. The right fallopian tube appeared normal; however, there were adhesions around the right ovary. The uterus appeared normal. There were no hernias. There was no endometriosis. The liver appeared normal. There were no perihepatic adhesions. The bowel appeared normal, except for the above-stated adhesions.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating table and underwent induction of general anesthesia via endotracheal tube. The patient was then placed in the dorsal lithotomy position in low adjustable Allen stirrups.

Examination under anesthesia revealed the above-stated findings. She was then prepped and draped in the usual sterile fashion. A Foley catheter was used to drain the bladder. A speculum was used to visualize the cervix. The anterior lip of the cervix was grasped with a single-tooth tenaculum. The uterus was sounded to 7 cm. A HUMI uterine manipulator was then inserted, and the balloon was inflated with 3 mL of air. The tenaculum was removed, and the tenaculum puncture sites were noted to be hemostatic. The speculum was removed leaving the uterine manipulator in place during the procedure.

The operator then changed gloves, and attention paid to the abdomen where the umbilicus was anesthetized with 0.25% Marcaine solution. A 5 mm stab wound was made through the umbilicus. This was carried down to the fascia, the anterior abdominal wall was elevated, and an Xcel visual trocar was inserted under direct laparoscopic visualization. Pneumoperitoneum was established, and the above-stated findings were noted.

An additional puncture site was made in the left lower quadrant by first finding an avascular area. This site was anesthetized with 0.25% Marcaine solution. A 1 cm incision was made in the left lower quadrant, and an Ethicon Xcel 10/12 mm blunt-tipped trocar was inserted under direct laparoscopic visualization. An Ace Harmonic scalpel was then used to very carefully perform an enterolysis freeing up the bowel and omentum from the anterior abdominal wall. On examination, all sites of viewed lysis noted, the bowel was completely free of any serosal injury. All sites of adhesion lysis were hemostatic.

Attention was then paid to the pelvis where a large mass was noted within the left broad ligament, appears to be arising form the left ovary with a large left hydrosalpinx and dense paratubal adhesions consistent with a tuboovarian complex, possible cystoadenoma with left hydrosalpinx. There were also filmy adhesions around the right ovary, and these were easily taken down. The right fallopian tube and ovary, however, were otherwise within normal limits.

An additional puncture site was made in the suprapubic area after first finding avascular area. The site was anesthetized with 0.25% Marcaine solution. A 5 mm stab wound was made at the suprapubic site and a 5 mm trocar inserted under direct laparoscopic visualization. The operative instruments were then inserted through this and used to dissect out the pelvic sidewall by first transecting the left round ligament. The anterior and posterior leaves of the broad ligament were opened with the Harmonic scalpel. Meticulous and careful dissection was used to dissect the mass off of the pelvic sidewall.

The left infundibulopelvic ligament was then identified, and this was coagulated with the Harmonic Ace in three separate locations and then transected. Then, a 0 Vicryl Endoloop suture was placed across the infundibulopelvic ligament as well with excellent hemostasis being achieved. The 0 Vicryl Endoloop suture was then cut with the mass further dissected off the left pelvic sidewall.

A small fenestration was then made in the medial aspect of the broad ligament just beneath the uteroovarian ligament and the fallopian tube at the cornua insertion and then a 0 Vicryl suture was passed through this fenestration and used to ligate the left fallopian tube and uteroovarian ligament at this site utilizing extracorporeal knot tying technique.

The fallopian tube and uteroovarian ligament were then transected with the Harmonic Ace scalpel, and the remainder of the mass was dissected free from the pelvic sidewall utilizing the Harmonic scalpel with careful and meticulous attention. The course of the left ureter was identified during this dissection process and noted to be free of any injury and noted to be peristalsing freely. There was an area of oozing from the uterus and a varicosity of the uteroovarian ligament, and this was rendered hemostatic with bipolar Kleppinger forceps.

Excellent hemostasis was achieved. The pelvic mass, once freed up, was placed within an Endobag, and this was brought up through the skin, perforated, drained, and then the mass was withdrawn out the left lower quadrant site. A large amount of serous, straw-colored hemorrhagic fluid was aspirated. This was saved per the patient’s request for a toxicology evaluation, and this was sent to pathology along with the mass. Note was made that the mass was drained within the Endobag.

The pelvis was then copiously irrigated and suctioned dry. Excellent hemostasis was noted throughout. The intraperitoneal pressures were decreased. There was no active bleeding noted in any of the sites. Left ureter could be seen peristalsing. Right ureter was also identified, and this was also seen peristalsing and appeared normal. The pelvis was suctioned dry. The 10/12 mm trocar in the left lower quadrant was then removed, and a Carter-Thomason fascial closure device was inserted. A 0 Vicryl suture was then passed through the fascia into the peritoneal cavity, and then under laparoscopic guidance, the suture was retrieved and withdrawn through the peritoneum and fascia.

The Carter-Thomason fascial closure device was removed, and the suture was closed thus closing the peritoneum and both layers of fascias together, and this was airtight to pneumoperitoneum. The fascia was palpated and noted to be free of any defects. The trocar site in the suprapubic area was then removed under direct laparoscopic visualization and noted to be hemostatic. The laparoscope was withdrawn, and the pneumoperitoneum was then evacuated. The laparoscope was reinserted, and the laparoscope and laparoscopic sleeve were removed together. The skin edges of the umbilical incision, suprapubic, and left lower quadrant sites were closed with 4-0 Vicryl subcuticular sutures, and Steri-Strips were applied.

Attention was then paid vaginally where the uterine manipulator balloon was deflated and removed. Excellent hemostasis was noted. The Foley catheter balloon was removed. The patient was placed once again supine upon the operating table and underwent reversal of anesthesia. She was extubated and taken to the postanesthesia care unit in a good condition. The patient tolerated the procedure well without complications.

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PREOPERATIVE DIAGNOSES:
1.  Intrauterine embryonic demise.
2.  Missed abortion.

POSTOPERATIVE DIAGNOSES:
1.  Intrauterine embryonic demise.
2.  Missed abortion.

OPERATION PERFORMED:  Suction and dilatation and curettage.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General LMA.

ANESTHESIOLOGIST:  Jane Doe, MD

INDICATIONS FOR OPERATION:  This is a (XX)-year-old G3, P3 with a known intrauterine demise, who by last menstrual period is 13 weeks and 5 days’ gestational age by ultrasound. Crown-rump length is 10 weeks with no cardiac activity and the diagnosis of intrauterine fetal demise. The patient was counseled and consented and given the option for conservative management, but she has opted for surgical management with the D&C. Risks, benefits, indications, and alternatives to the procedure were reviewed with the patient, and informed consent was obtained.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room with an IV running. She underwent general anesthesia with LMA without complication and was placed in a supine position. In the low lithotomy position, the patient was prepped and draped in the usual sterile fashion. In-and-out catheterization of the bladder produced 150 mL of urine.

The cervix was exposed using a bivalve speculum. Single-toothed tenaculum was placed on the anterior lip of the cervix. The cervix was dilated with Hanks dilator and then #10 curved suction curette was advanced to the fundus of the uterus, and the machine was activated and commenced with the suction D&C.

Two passes were performed, and then after that, we proceeded with the sharp curette obtaining a gritty texture in all quadrants. Once again, suction curetted. Uterus was hemostatic. With this, we terminated the procedure. All the instruments were removed from the patient.

The procedure was well tolerated. Estimated blood loss was minimal, and the patient was taken down from the lithotomy position, awakened from anesthesia, and taken to the recovery room in stable condition. Sponge and laps were correct x2, and there were no complications.

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PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Menorrhagia.

POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Menorrhagia.
3. Endometriosis.
4. Right paratubal cyst.

OPERATION PERFORMED:
1. Laparoscopic laser fulguration of endometriosis.
2. Removal of right paratubal cyst.
3. Hysteroscopy.
4. NovaSure endometrial ablation.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

IV FLUIDS: 800 mL.

ESTIMATED BLOOD LOSS: Minimal.

OPERATIVE FINDINGS: Endometrial implants on the bilateral ovaries, bilateral pelvic sidewalls, and within the posterior cul-de-sac. The appendix, gallbladder, and liver were all grossly within normal limits.

DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the operating room where general anesthesia was found to be adequate. She was then prepped and draped in the normal sterile fashion and placed in dorsal lithotomy position.

A bivalve speculum was first placed in the patient’s vagina, and the anterior lip of the cervix was grasped with an Allis clamp. The uterus was then gently sounded to 9 cm, and an 8 cm long Harris-Kronner uterine manipulator injector device was then entered atraumatically into the cervix in order to provide better uterine manipulation during the laparoscopic part of the case. The cervix was first gently sounded until the HUMI was easily advanced through the cervix. The Allis clamp and the bivalve speculum were then removed.

Attention was then turned to the patient’s abdomen where a 5 mm skin incision was then made vertically in the umbilical fold. The 5 mm Step Veress needle was then advanced without difficulty into the pelvis. The 5 mm trocar was advanced as well, and the pelvis was then insufflated with approximately 3 liters of CO2 gas. Intraperitoneal placement was confirmed under direct visualization using the laparoscope.

A second 5 mm skin incision was then made suprapubically and another 5 mm Step trocar was advanced without difficulty into the pelvis under direct visualization of the laparoscope. A blunt probe was placed through this port and then we identified and viewed the pelvic anatomy. We visualized the liver and gallbladder and located the appendix, which all appeared to be grossly within normal limits. We then viewed the pelvis, and the uterus appeared to be grossly within normal limits. The bilateral ovaries appeared to be normal. However, there were several endometrial implants on each ovary. There was enough evidence of endometrial implants along the bilateral pelvic sidewalls and also within the posterior cul-de-sac. The anterior cul-de-sac appeared to be free of any disease. We located the ureters on either side.

At that point, we placed another 5 mm Step trocar in the patient’s left lower quadrant under direct visualization using laparoscope as well. The periumbilical port was switched out for a 5 mm size. We then turned to the laser portion of the case. We first tested the laser and the CO2 and argon beam in order to ensure its integrity. The laser was advanced through the 10 mm periumbilical port. The laser was then used to fulgurate multiple areas of endometriosis within the pelvis.

Again, there were several areas on the bilateral ovaries and also on the bilateral pelvic sidewalls. Through the left lower quadrant site, we were able to advance a grasper in order to pull the peritoneum away from the sidewall at times when we desired to laser an area of endometriosis. This was done to ensure that we were far from the vessels and also the ureter. We also ablated several areas using the laser on the bilateral broad ligaments, and within the posterior cul-de-sac, there were a couple of areas as well. There was a small paratubal cyst noted on the right tube. This was attached at several places to the tube and also the right pelvic sidewall. The laser was used in order to remove the small paratubal cyst, and it was then removed from one of the smaller ports.

Periodically, the pelvis was irrigated. There was excellent hemostasis noted, and there was really no bleeding during the case. Once we felt that we had essentially fulgurated all the possible endometriosis that we found, the laser was removed. The remainder of the instruments was removed from the pelvis. The fascia and the 10 mm port were closed with 2-0 Vicryl, and the skin incisions were all closed with 4-0 Vicryl in a subcuticular fashion.

We then turned our attention to the pelvis and began the ablation part of the procedure. Since the uterus had previously been sounded to 9 cm and the cervix was approximately 4 cm, we set the length of the NovaSure device to 5 cm. We placed the NovaSure device atraumatically through the cervix after the cervix had been grasped again anteriorly with an Allis clamp. The ablation device was then expanded within the uterus and manipulated in several ways in order to achieve a maximum width of 4.4 cm. The NovaSure device was then set accordingly. We first activated the ablation device as a test to ensure the integrity of the cavity. Once this was established, the ablation began and the burn lasted approximately 90 seconds. The NovaSure device was then removed atraumatically through the cervix.

A 5 mm hysteroscope was advanced to visualize the endometrial cavity, which appeared to have excellent burn within all four quadrants. The hysteroscope was then removed. The Allis clamp was removed from the cervix as well, which also appeared to be hemostatic, and the speculum was removed as well. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room in stable condition.

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PREOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 40 weeks.
2.  Frank breech position.

POSTOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 40 weeks.
2.  Frank breech position.

OPERATION PERFORMED:  Primary low transverse cesarean section with two-layer closure.

SURGEON:  John Doe, MD

ANESTHESIA:  Spinal anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  500 mL.

URINE OUTPUT:  200 mL.

IV FLUIDS:  1300 mL crystalloid. Ancef 1 gram at cord clamp IV.

OPERATIVE FINDINGS:  Normal male infant with Apgars of 8 and 9 at one and five minutes with weight of 6 pounds 8 ounces.

DESCRIPTION OF OPERATION:  After informed consent, risks and benefits of the procedure was discussed with the patient. The patient was taken to the operating room where she was placed in the dorsal lithotomy position with leftward tilt. After placement of spinal anesthesia, which was found to be adequate, she was then prepped and draped in the usual sterile fashion.

A Pfannenstiel skin incision was made with a scalpel and carried through to the underlying layer of fascia. The fascia was then nicked in the midline, extending bilaterally and sparing the inferior aspects. The fascia was dissected off the rectus muscles bluntly. The rectus muscles were separated in the midline, and peritoneum was identified, entered with hemostat, and extended superiorly and inferiorly with good visualization of the bladder.

The bladder blade was then inserted. The vesicouterine peritoneum was identified and entered sharply with Metzenbaum scissors and extended bilaterally and then the bladder flap was created digitally. The uterine incision was then made with the scalpel and extended with bilateral index fingers in a crescent-shaped fashion. The fetal buttocks were then grasped and bilateral legs were delivered, and the infant was delivered in the usual fashion of a beech delivery, atraumatically. The cord was clamped and cut. The infant was then handed off to the awaiting pediatric staff. The placenta was then delivered spontaneously, intact.

The cervix was then dilated with ring forceps. The uterus was then exteriorized and cleared of all clots and debris. The uterine incision was then closed with 1-0 chromic in a running locked fashion. A second layer of the same suture was used in an imbricating fashion for hemostasis. The uterus was then returned to the abdomen. Bilateral gutters were cleared off all clots and debris. The uterine incision was noted to be hemostatic.

The subfascial layer was noted to be hemostatic, and the fascia was closed with 1-0 Vicryl in a running fashion. The subcutaneous layer was then closed with 3-0 Vicryl in a subcutaneous fashion. The skin was closed with 4-0 Vicryl in a subcuticular fashion. Steri-Strips, Telfa, and Tegaderm dressing were applied. All instruments, needle, and lap counts were correct x2. The patient was taken to the recovery room in stable condition.

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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.

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DATE OF DISCHARGE: MM/DD/YYYY

DISCHARGE DIAGNOSES: Intrauterine gestation at term, in labor, previous cesarean section, multiparity, fertility, desired sterilization, delivery of viable female infant.

PROCEDURES: Repeat low transverse cesarean section, bilateral tubal ligation, and lysis of adhesions.

COMPLICATIONS: None. Level of pain at discharge, mild, 3/10.

PERTINENT FINDINGS AND HISTORY: Please refer to the detailed admission dictation as well as the written history and physical. The patient is a (XX)-year-old gravida 2, para 1 female with an EDC of MM/DD/YYYY, who presented at 38.6 weeks gestation in labor with contractions recurring every 1-1/2 to 2 minutes of moderate intensity. The patient had history of having undergone a primary cesarean section with her first pregnancy in YYYY for failure to descend. Our plan with this pregnancy was to proceed with a repeat cesarean section. The patient also strongly desired sterilization at the time of this delivery. She had been counseled regarding the permanency, failure rates, risks, and options. Her antenatal course had been benign. She did have a history of asthma and was using Advair twice daily along with Zyprexa and albuterol nebulizers as needed. The patient has not had any recent problems with her asthma. On admission, examination revealed the patient was afebrile with a temperature of 97.8 degrees, blood pressure 118/78, pulse 82, and respirations 18. HEENT, neck, heart, lungs, abdomen, extremity, calf, thigh, and neurologic examinations all were within normal limits. Estimated fetal weight of the infant was over 7 pounds. The cervix was 1 cm dilated, 60% effaced with membranes bulging with the vertex at -2 station. There was no pedal edema. The fetal heart tracing was reassuring and reactive. The contractions were recurring every 1-1/2 to 2 minutes. The patient was uncomfortable on admission.

HOSPITAL COURSE: Please refer to the admission dictation for the patient’s antenatal laboratory investigations and admission laboratory investigations. The patient’s postoperative hematocrit was 30.7. The patient was admitted and prepared for repeat cesarean section and sterilization. Informed consent was obtained. Brethine was administered initially to slow the contractions, as we were preparing for the cesarean section. In the afternoon, under spinal anesthesia, an uncomplicated repeat low transverse cesarean section and bilateral tubal ligation were performed. Anterior uterine surface for abdominal adhesions were lysed at delivery. A viable female infant with Apgars of 8 and 9 and cord pH of 7.32 was delivered. Birth weight was 7 pounds 8 ounces. There were no intraoperative or perioperative complications.

The patient’s postoperative course was uneventful. She was bottle-feeding. She remained afebrile with stable vital signs. She quickly returned to good ambulation, a regular diet, and moved her bowels prior to discharge. By the morning of the second postoperative day, she was anxious to go home. She was having mild pain, controlled with Percocet. Her examination revealed clear lungs, irregular heart rate and rhythm, negative breast, abdomen incision, calf, thigh, and neurologic examination. Lochia was normal. Fundus was firm. The patient had no respiratory problems during the postoperative period. She was maintained on her home medications.

CONDITION AT DISCHARGE: Stable.

DISPOSITION: Discharged to home.

DISCHARGE INSTRUCTIONS: Activity: Slowly increase as tolerated. No heavy lifting. No pushing. No straining. Strict pelvic rest. Diet: Regular.

DISCHARGE MEDICATIONS: Prenatal vitamins. The patient will continue on her Advair and her other asthma medicines as needed. Colace once or twice daily as needed. Prescriptions for Percocet 325/5 tablets, #30, no refills, one to two every four to six hours as needed for pain and ibuprofen 800 mg tablets, #30, no refills, one tablet three times daily with food as needed for pain.

FOLLOWUP: The patient will be seen in the office in one week.

Prior to discharge, the patient received routine verbal and written instructions and agreed to comply. We went over all signs and symptoms of complications. The patient knows to contact immediately should she develop any issues such as fevers, chills, heavy bleeding, neurological problems such as dizziness, weakness, blurry vision, abdominal distention with nausea and vomiting, drainage from the incision, redness, tenderness, swelling of the calves or thighs or certainly chest pain, chest pressure, shortness of breath, cough, sputum or wheeze.

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PREOPERATIVE DIAGNOSIS: Menometrorrhagia.

POSTOPERATIVE DIAGNOSIS: Menometrorrhagia.

OPERATION PERFORMED:
1. Dilation and curettage of the uterus.
2. Hysteroscopy.
3. ThermaChoice ablation.

SURGEON: John Doe, MD

ANESTHESIA: General LMA.

OPERATIVE FINDINGS: Intrauterine adhesive band and trace adenomyosis of the fundus.

HYSTEROSCOPIC FLUIDS: Intake 500 mL, output 450 mL for a deficit of 50 mL normal saline.

ESTIMATED BLOOD LOSS: Less than 25 mL.

DRAINS: None.

IMPLANTS: None.

SPECIMENS: Endocervical curettage and endometrial curettings.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. After adequate general LMA anesthesia, she was transferred to the dorsal lithotomy position. She was prepped and draped in the usual sterile fashion. Examination under anesthesia revealed the uterus to be very retroverted, approximately 8-9 weeks in size, with first to second-degree uterine descensus and no adnexal masses.

A weighted speculum was inserted inside the vagina. The anterior lip of the cervix was grasped with a sharp-tooth tenaculum. The uterus sounded to 8 cm. The cervix was serially dilated up to #23 Hegar dilator and then diagnostic hysteroscopy using a 3 mm VersaScope was used with normal saline as the hysteroscopic fluid. There was a positive fluid balance of about 50 mL. The uterus was visualized, and the patient was noted to have some filmy adhesions in the endocervical region as well as a band of tissue extending from left to the right side of the uterus in the midline that appeared to be an adhesive band and was not a septum. It appeared to be consistent with proliferative endometrial tissue, and both tubal ostia were visualized and were noted to be normal.

Then, the hysteroscope was removed, and the cavity was curetted until the band was removed and this also explored with polyp forceps. The hysteroscopy was performed again, and the cavity was noted to be free of any intrauterine adhesions. The patient was felt to be a good candidate for an ablation. Therefore, the ablation was performed using the ThermaChoice 3 ablation balloon. The balloon was first checked using 5 mL of D5W, and the balloon appeared to be intact. It was inserted in to the uterine cavity after withdrawing to negative pressure to 160 mmHg and then inserted into the cavity, achieving a pressure of 180 mmHg. After consistent sustained pressure of 180 mmHg, the 8 minute heating cycle was performed. Then, the instrument was allowed to cool down, was removed from the uterus after emptying the balloon, and then the tenaculum was removed and the cervix was cauterized with silver nitrate. Good hemostasis was obtained.

At the end of the procedure, all instruments were then removed from the vagina. The patient was placed back in the supine position and awakened and taken to the recovery room in stable condition. There was correct sponge, needle, instrument count at the end of the procedure.

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