DATE OF OPERATION: MM/DD/YYYY
POSTOPERATIVE DIAGNOSIS:
Cervical intraepithelial neoplasia, grade 3 with positive ECC.
OPERATION PERFORMED:
Loop electrosurgical excision procedure with top hat and endocervical curettings.
SURGEON: John Doe, MD
ANESTHESIA:
General anesthesia.
INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old G1 with a history of abnormal Pap smear. A colposcopy demonstrated CIN 3 with ECC also demonstrating CIN 3. The patient has no significant past medical history. Past surgical history is significant just for a right breast biopsy. OB history: The patient is nulliparous. The patient was advised to undergo a LEEP procedure with ECC. All risks and benefits were discussed with the patient including potential risk of preterm labor, cervical incompetence and preterm premature rupture of membranes should she become pregnant in the future. The patient accepted these risks. All questions were answered and the patient was taken to the operating room in stable condition.
PERTINENT FINDINGS:
Bimanual examination revealed a normal sized midline uterus with no adnexal masses palpated. Cervix did not appear to have any gross masses. Lugol’s solution revealed areas of non-uptake around the entire squamocolumnar junction.
SPECIMENS:
Ectocervix with anterior and posterior portions, endocervical specimen from the top hat, endocervical curettings.
ESTIMATED BLOOD LOSS:
Minimal.
IV FLUIDS:
600 mL of lactated Ringer’s.
DESCRIPTION OF PROCEDURE:
The patient was taken to the OR where she was placed under general anesthesia without difficulty. She was then prepped and draped in the usual sterile fashion and placed in the dorsal lithotomy position. A preoperative bimanual examination revealed findings as above. A preoperative beta quantitative test was negative for pregnancy as well.
At this time, the large Graves speculum was placed in the vagina. Lugol’s solution was painted along the entire cervix and vaginal wall. Areas of non-uptake were noted to be around the entire squamocolumnar junction. Approximately 20 mL of diluted vasopressin was injected circumferentially along the cervix. The large loop electrode was used to remove the anterior or top portion of the cervix and a separate posterior specimen was excised and sent to pathology. The smallest loop electrode was used to obtain a top hat for excision of the endocervix. An endocervical curettage was performed and specimen was placed on a Telfa pad and sent to pathology.
The bed of the excised cervical tissue along the cervix was cauterized using the roller ball. Hemostasis was noted. All instruments were removed from vagina at this point. The patient tolerated the procedure well without complication and was taken to the recovery room in stable condition.
