PREOPERATIVE DIAGNOSIS: Cervical dysplasia and menorrhagia.
POSTOPERATIVE DIAGNOSIS: Cervical dysplasia and menorrhagia.
PROCEDURES PERFORMED:
1. Hysteroscopy.
2. Dilatation and curettage.
3. Endocervical curettage.
4. LEEP procedure.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 20 mL.
FINDINGS: Normal-appearing cervix with stenotic os, endometrial cavity noted to have normal-appearing proliferative tissue.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where she was placed under general anesthesia in the dorsal lithotomy position for hysteroscopy, dilatation and curettage, and above procedures. She was prepped and draped in the normal sterile fashion.
The patient’s bladder was not drained. Using the Sims retractors, the cervix was visualized, and the anterior lip of it was grasped with a single-tooth tenaculum. The cervical os was found to be stenotic, and the lacrimal probe dilators were used to dilate the cervical canal.
A small Hanks dilator was then advanced without difficulty, and further dilatation was accomplished using subsequently larger Hanks dilators.
The hysteroscope was introduced to the uterine cavity without difficulty. Normal-appearing proliferative tissue was visualized. No pictures were taken.
After removing the hysteroscope, a gentle curettage was undertaken. Endocervical curettage was also performed at this time.
Next, attention was turned to the external cervix, which was thoroughly dried. A green loop was chosen for the LEEP procedure. Cervix was removed without difficulty. The exposed cervix was then treated with roller ball cautery. Good hemostasis was noted.
The anterior lip of the cervix was grasped with a tenaculum and removed and again good hemostasis was noted. The patient tolerated the procedure well. The patient was taken to the recovery room in stable condition. All counts were correct.
PATHOLOGY:
1. Endometrial curettings.
2. Endocervical curettings.
3. Cervical specimen, status post LEEP procedure.
Dilatation and Curettage Sample Report #2
PREOPERATIVE DIAGNOSIS: Incomplete abortion.
POSTOPERATIVE DIAGNOSIS: Incomplete abortion.
PROCEDURE PERFORMED: Dilatation and curettage, suction evacuation of uterus.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMEN TO PATHOLOGY: Products of conception.
ESTIMATED BLOOD LOSS: 60 mL.
INDICATIONS FOR OPERATION: This is a (XX)-year-old G 10, P 4-0-5-4, who was at 13 weeks by ultrasound who had an incomplete abortion.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed under general anesthesia for dilatation and curettage. She was prepped and draped in the normal fashion.
Sterile speculum was placed in the patient’s vagina, and the cervix was noted to be dilated. The products of conception were present at the os and removed intact. The cervix and vagina were then swabbed with Betadine, and a single-tooth tenaculum was applied to the location at the top of the cervix.
The uterus was then gently suction curetted and rotated to clear the uterus of products of conception. A sharp curettage was then performed until a gritty texture was noted. The suction curette was then reintroduced to clear the uterus of all remaining products of conception.
There was minimal bleeding noted, and the tenaculum was removed with good hemostasis noted. The patient tolerated the dilatation and curettage well and was taken to the recovery area in stable condition.
