D&C and hysteroscopy Operative Report

PREOPERATIVE DIAGNOSIS:  Dysfunctional uterine bleeding.

POSTOPERATIVE DIAGNOSIS:  Dysfunctional uterine bleeding.

PROCEDURE:  D&C and hysteroscopy.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

ANESTHESIA:  Spinal.

SPECIMEN:  ECC and EMC.

FINDINGS:  Second endometrial lining, scant polypoid tissue, bilateral ostia visualized.

PROCEDURE IN DETAIL:  This is a 34-year-old with dysfunctional uterine bleeding, endometrial polyp seen on ultrasound.  The patient is attempting to get pregnant.  Risks, benefits and alternatives discussed with the patient at length.  Informed consent was obtained.  The patient was taken to the operating room.  General anesthesia was obtained without difficulty.  She was then prepped and draped in the lithotomy position in candy-cane stirrups.  Examination under anesthesia revealed a small anteverted uterus.  No adnexal masses were palpable.  A weighted speculum was placed inside the vagina.  The anterior lip of the cervix grasped with single-tooth tenaculum.  ECC was taken.  The cervix was gently dilated to ensure reduction with diagnostic hysteroscope.  The hysteroscope was introduced into the uterine fundus.  Both ostia were easily visualized.  The cavity appeared smooth.  There was some thickening of endometrium with some scant polypoid tissue on the posterior wall.  The hysteroscope was removed.  Sharp curettage followed.  Tissue was obtained.  There was polypoid tissue noted in the specimen.  All instruments removed from the vagina.  Hemostasis was achieved.  The patient was awakened and taken to the recovery room in stable condition.