LEEP / cold-knife conisation of cervix

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding during the procedure or up to 3 weeks later
• infection of cervix, uterus or tubes
• incomplete removal (positive margins) and need for further treatment
• cervical stenosis
• preterm birth in a future pregnancy
• uterine perforation
• injury to bladder or rectum
• vaginal burn (LEEP)

Pre-operative details for this operation

1. IndicationPap result, colposcopy impression, biopsy result (CIN grade / AIS / suspected microinvasion), ECC result
2. Transformation zone on colposcopyFully seenNot fully seen (inadequate colposcopy)
3. Pregnancy excludedLMP and urine pregnancy test. Excision is deferred in pregnancy until 6 weeks postpartum
4. Future fertility wishWants childrenFamily completedecides how deep and how wide to cut
5. Anticoagulants stoppeddrug and date stopped, or 'not on any'
6. Procedure chosen and reasonLEEPCold-knife coneCKC if invasion suspected, endocervical lesion, AIS, or cervix not suited to loop sizes

Anaesthesia and position

1. AnaesthesiaLocal intracervical infiltrationSpinal + localGeneral + local
2. Local anaesthetic / vasoconstrictordrug, strength and volume: e.g. 1% lignocaine with adrenaline 1:100,000, 10-20 ml, or dilute vasopressin
3. PositionLithotomy
4. LEEP set-upinsulated (non-reflective) speculum, smoke evacuator attached, diathermy return plate site, generator settings

Operative findings

1. Examination under anaesthesiauterus size and position, parametria, vagina
2. Cervixsize, shape, os, any visible growth or ulcer
3. Lugol / acetic acid stainingarea of non-staining (Lugol) or acetowhite change, and where the squamocolumnar junction lies
4. Vaginal extension of lesionNonePresent (site)

Procedure (steps)

1. Vaginal preparation and drapingantiseptic used
2. ExposureWeighted speculum + anterior retractorInsulated speculum (LEEP)
3. Squamocolumnar junction marked outLugol iodine5% acetic acid
4. Intracervical infiltrationdrug, strength, volume, until the cervix blanches
5. Stay sutures / tractionStay sutures at 3 and 9 o'clockTenaculum outside the excision lineRing forcepssuture material, e.g. polyglactin 910 (Vicryl)
6. Excision: cold knifeNo. 11 blade, circumferential incision started at 6 o'clock, cone shape (flat for ectocervical, cylindrical for endocervical lesion), cone freed at the apex with knife or scissors
7. Excision: looploop size (width x depth), cut / blend setting and power, direction of pass (side to side / top to bottom), number of passes
8. Top hat (second endocervical pass)Not doneDoneloop size, reason (TZ not fully seen, high ECC)
9. Endocervical curettage after excisionDone, sent separatelyNot done
10. Specimen orientationstitch at 12 o'clock, specimen intact or in pieces
11. Haemostasis of cone bedBall diathermyMonsel solutionRunning locked suture of edgesSturmdorf suturesGelatin sponge

Closure, drains and dressing

1. Stay suturesCut and leftRemoved
2. Vaginal packNonePlacedif placed: number of packs and time of removal
3. Bladdercatheter placed / not needed, urine colour
4. Bleeding at enddry / ooze controlled

Specimens and implants

1. Cone / LEEP specimen for HPEintact or pieces, 12 o'clock stitch, measured depth, in formalin, requisition with clinical details
2. Top-hat specimenSent in separate containerNot applicable
3. Endocervical curettingsSent in separate containerNot done

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals and vaginal bleedingpad check; call if more than one pad soaked per hour or clots
2. Vaginal pack / cathetertime of removal if placed
3. Oral intake and mobilisationwhen to start after anaesthesia
4. Analgesiadrug, dose, frequency
5. Pelvic restno intercourse, tampons or douching for 4 weeks
6. Warning signs on dischargeheavy bleeding (can occur 10 to 21 days after, when the eschar separates), fever, foul discharge
7. HPE follow-update to review margins and ECC report
8. Surveillancerepeat Pap and ECC at 6 months if margins involved

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery