DATE OF OPERATION: MM/DD/YYYY
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.
