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Cautery of cervix; laser ablation

CPT4 code

Name of the Procedure:

Cautery of Cervix; Laser Ablation

Summary

Laser ablation cautery of the cervix is a medical procedure where a laser is used to burn away abnormal or diseased tissue of the cervix. This is usually done to treat cervical dysplasia or precancerous lesions.

Purpose

The medical condition or problem it addresses:
  • Cervical dysplasia or precancerous lesions on the cervix.
The goals or expected outcomes of the procedure:
  • To remove abnormal tissue and prevent the development of cervical cancer.

Indications

Specific symptoms or conditions that warrant the procedure:
  • Abnormal Pap smear results.
  • Biopsy-confirmed cervical dysplasia.
  • Persistent HPV (Human Papillomavirus) infection with evidence of cervical changes.
Patient criteria or factors that make the procedure appropriate:
  • Non-pregnant women of reproductive age.
  • Patients who have completed childbearing may also be candidates.

Preparation

Pre-procedure instructions for the patient:
  • Abstain from sexual intercourse, douching, or using any vaginal medications for 24-48 hours before the procedure.
  • Follow specific instructions from the healthcare provider regarding fasting or medication adjustments.
Any diagnostic tests or assessments required beforehand:
  • Pap smear and HPV testing.
  • Colposcopy and cervical biopsy to determine the extent of abnormal tissue.

Procedure Description

Detailed step-by-step explanation of what the procedure involves:
  1. The patient lies on an exam table with feet placed in stirrups.
  2. A speculum is inserted into the vagina to expose the cervix.
  3. A local anesthetic may be applied to numb the cervix.
  4. The laser device is used to precisely target and remove the abnormal tissue.
  5. The area is then examined to ensure all affected tissue has been treated.
Tools, equipment, or technology used:
  • Colposcope (to view the cervix).
  • Laser device for ablation.
Anesthesia or sedation details:
  • Local anesthesia around the cervix to minimize discomfort.

Duration

  • The procedure typically takes about 10 to 30 minutes.

Setting

  • Outpatient clinic or gynecologist's office.

Personnel

  • Gynecologist or specialized physician.
  • Assisting nurse or medical assistant.

Risks and Complications

Common and rare risks associated with the procedure:
  • Mild to moderate cramping or discomfort.
  • Light vaginal bleeding or spotting.
  • Infection (rare).
  • Scarring of the cervix, which could affect future pregnancies (rare).
Possible complications and their management:
  • Any signs of infection, such as fever or unusual discharge, should be reported immediately to a healthcare provider.

Benefits

Expected benefits and how soon they might be realized:
  • Effective removal of abnormal cervical tissue.
  • Reduced risk of progressing to cervical cancer.
  • Most benefits are realized within a few weeks as the cervix heals.

Recovery

Post-procedure care and instructions:
  • Avoid strenuous activity, sexual intercourse, and tampon use for about 2-4 weeks.
  • Follow-up appointments to monitor healing and ensure all abnormal tissue was removed.
Expected recovery time and any restrictions or follow-up appointments:
  • Full recovery usually takes about 4-6 weeks.
  • A follow-up Pap smear or colposcopy may be scheduled within 3-6 months.

Alternatives

Other treatment options available:
  • Cryotherapy (freezing abnormal cells).
  • Loop Electrosurgical Excision Procedure (LEEP).
  • Cone biopsy or cervical conization.
Pros and cons of alternatives compared to the described procedure:
  • Cryotherapy: Less precise but effective for certain types of lesions.
  • LEEP: Uses electric current to remove tissue, may have a higher risk of complications.
  • Cone biopsy: More invasive, used if a larger area of tissue needs removal.

Patient Experience

What the patient might feel or experience during and after the procedure:
  • Slight discomfort or cramping during the procedure.
  • Mild to moderate cramping and light bleeding or discharge for a few days after.
Pain management and comfort measures:
  • Over-the-counter pain relievers (e.g., ibuprofen) may be recommended.
  • Rest and avoidance of irritative activities to promote healing.

This markdown provides a structured, comprehensive overview of the laser ablation cautery of the cervix procedure suitable for patient education.

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