REFERENCE

CODE
FM-MED-
Republic of the Philippines
OBG-002
Department of Health
REV. NO.
EAST AVENUE MEDICAL CENTER
0
DEPARTMENT OF OBSTETRICS AND
DATE
GYNECOLOGY
EFFECTIVE:
SEPTEMBE
R 2014
Date: March 3, 2023

Name: GAZA, CYRIL Age: 43

Pre-operative Diagnosis: G0, AUB-L, prolapsed submucous myoma, anemia, mild
Post-operative Diagnosis: G0, AUB-L, prolapsed submucous myoma, s/p vaginal
myomectomy (coring technique) followed by endometrial biopsy under spinal
anesthesia, anemia, mild, ongoing correction
Operation performed: Vaginal myomectomy (coring technique) followed by
endometrial biopsy under spinal anesthesia
Surgeon: Ma. Kristina Barbara O. Reyes, MD

Operative Technique
Patient placed in supine position under spinal anesthesia.
Bladder catheterized aseptically.
Pelvic examination done:
Internal examination: Prolapsed within the vaginal canal is a doughy mass
measuring 5x 4 cm. The stalk measures 3 x 2 cm seemingly attached to the
anterior uterine wall. The cervix is palpated. The uterus is not enlarged and no
adnexal mass noted.
Povidone iodine scrub and antiseptic used for vaginal, perineal and abdominal skin
preparation.
Sterile drapes placed.
Proceeded with vaginal myomectomy using the coring technique:
The myoma was grasped using a tenaculum forceps.
A wedge resection was made to excise the core of the myoma. Procedure was
repeated until the pedicle of the myoma was appreciated.
The pedicle was then excised
The specimen was sent for histopathology
Proceeded with endometrial biopsy:
Vaginal retractors applied.
Cervix visualized.
Anterior lip of the cervix grasped with Allis forceps.
Uterine depth measured.
Biopsy of endometrium using sharp curettage.
Hemostasis observed.
 Removal of Allis forceps and vaginal retractors.
Internal examination done.
Drapes removed.
Patient tolerated the procedure well.

Specimen (1) Myoma, (2) endometrial curetting

Ma. Kristina Barbara O. Reyes, MD

License # 0141593
Surgeon