Dictation for LEEP

 

PreOperative Diagnosis: ***

Post Operative Diagnosis: Same

Procedure: Loop Electrosurgical Excision Procedure

Surgeon: ***

Assistant: ***

Anesthesia: IV sedation

Complications: none

IVF: ***

EBL: <25 cc

Findings: ***

Specimens: ***

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Indications: *** yo G***P*** presenting with *** on pap/colpo. 

 

Procedure: The patient was met in pre-operative holding and the procedure was again reviewed with the patient. She was then taken to the OR and intermittent compression devices were placed on her calves bilaterally and she was given IV sedation. She was placed in the dorsal lithotomy position and prepped and draped in the usual sterile fashion. A nonconductive speculum with the smoke evacuator attached was placed into the vagina. Acetic acid (or Lugol’s depending on which is used) solution was applied to the cervix. ***5 cc of 1% lidocaine with epinephrine 1: 100,000 was injected.

A *** loop device was applied to the cervix to remove the specimens above.

A 5mm rollerball electrode was applied with the coagulation setting on the entire base of the excision. Monsel’s solution was applied and good hemostasis noted.

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Pt tolerated the procedure well and was taken to the recovery area in stable condition.

 

Dictation for Cone Bx- Same as above except for procedure

Procedure:

The cervix was coated with Lugol’s solution to identify the lesion. The anterior lip of the cervix was grasped with the tenaculum and **1%lidocaine was injected into the cervical stroma lateral to the area to be resected. A #11 blade was used to make a circumferential incision lateral to the transformation zone, pushing in a saw-like pattern lightly around. The specimen was then grasped with an Allis and Mayo scissors were used to cut it at the base. Currettage was then performed on the residual canal. Coagulation with a 5mm rollerball electrode was used at the entire base of the exicision. Monsel’s solution was applied and good hemostasis was noted. Patient toleratded the procedure well and went to recovery room in stable condition.