ANESTHESIA: General,
conscious sedation.
POSTOPERATIVE
DIAGNOSIS: Cervical
dysplasia.
OPERATION
PERFORMED:
1.
Cervical colonization, cold knife.
2.
Endocervical curettings.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less
than 30 mL.
DISPOSITION: The
patient was transferred to the recovery room in a stable condition.
JUSTIFICATION: The
patient presented on 05/15/09
for the above procedures, for the above diagnosis. The patient understands the indications,
rationale, potential complications, and risks.
She is aware that these risks include infection, bleeding, injury to
adjacent structures such as the bowel or bladder as well as potential cardiac
or pulmonary complications, and risk of anesthesia. The patient is aware of the potential for
thromboembolic events including deep venous thrombosis, stroke, and pulmonary
embolus. She is aware of the potential
for alteration in the cervical anatomy including potential future limitations
for pregnancy carriage and fertility.
All of the patient's questions have been answered apparently to her
satisfaction. The patient has elected to
proceed with surgery and is medically cleared.
PROCEDURE IN
DETAIL: Following documentation of informed consent
for the above procedures, the patient was brought to the operative suite where
she was administered general anesthesia, prepped and draped in the usual
sterile fashion in the low lithotomy position in Allen stirrups. A weighted speculum was placed in the vaginal vault. A single tooth tenaculum was placed on the
anterior lip of the cervix. The cervix
was infiltrated with dilute pitressin solution.
Excision of the transformation zone was accomplished to a level
approximating 3 to 4 mm depth. Top hat
samples were taken above the resection margin with the LEEP electrode. Endocervical curettings were sampled above
the top hat. Exact hemostasis was
secured within the resection bed utilizing the Bovie ball cautery. Mastisol solution was applied to promote ongoing
hemostasis. All instruments were removed
from the vagina and perineum. The patient was awakened from anesthesia and
returned to the recovery room in a stable condition.
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