DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Septic abortion.
POSTOPERATIVE DIAGNOSES:
1. Septic abortion at 3 to 6 weeks’ gestational age.
2. Missing intrauterine device.
OPERATION PERFORMED:
IUD removal under anesthesia followed by suction, dilatation, and curettage under ultrasound guidance.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia by the way of oral endotracheal intubation.
FLUIDS: Crystalloid 1 liter.
ESTIMATED BLOOD LOSS: 100 mL.
URINARY OUTPUT: 50 mL.
FINDINGS: IUD and products of conception.
COMPLICATIONS: None.
SURGICAL COUNTS: Correct.
DRAINS: None.
SPECIMENS: IUD and products of conception to pathology.
DISPOSITION: The patient left to recovery room in stable condition.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in dorsal supine position. She was then placed under general anesthesia and intubated. The patient was then placed in dorsal lithotomy position and was prepped and draped in the usual fashion. The bladder was drained of approximately 50 mL of clear urine. The patient was examined under anesthesia with notation of anteverted uterus, normal size, smooth, mobile, and nontender. There were no adnexal masses. The Graves speculum was placed into the vagina by exposing the cervix. It was then grasped on its posterior lip with a single-tooth tenaculum. Initial attempt to remove the IUD was without success. Finally, small ring forceps was placed into the internal os, and the IUD was grasped at its base and subsequently removed. The IUD appeared to be a Lippes loop. This was sent to pathology for cultures. Cervical os was then serially dilated to the sufficient size from all passes of a 9 mm curved catheter. The uterus had been previously sounded to approximately 9 cm with a regular contour. The products of conception were then placed on suction and followed by light curetting. No adequate uterine cry was noted. Several additional attempts were noted to remove products of conception. Subsequently, we obtained an ultrasound and completed the procedure under ultrasound guidance with the suction tip catheter and curette going to the remaining pregnancy with notation of gestational sac. No obvious fetal pole was appreciated. Products of conception were then removed and suctioned. Finally, at the procedure’s end, the uterine cavity was again lightly curetted with notation of an adequate uterine cry in all quadrants. One final pass at dissection was performed. Cervix was observed for hemostasis, which was noted. The single-tooth tenaculum was subsequently removed, and the products of conception sent to pathology. Speculum was also removed. Hemostasis was established. The patient was then returned to the dorsal supine position. Subsequently, the anesthesia was reversed. She was extubated and taken to the recovery room in stable condition.
