General Surgery Medical Transcription Operative Sample Reports For Medical Transcriptionists


DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment.
 
POSTOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment with poor peripheral venous access.
 
OPERATION PERFORMED:  Insertion of a 7.8 French pre-assembled Deltec ProPort via right subclavian.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  Local 0.25% Marcaine with MAC.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
ESTIMATED BLOOD LOSS:  Minimal.
 
BLOOD TRANSFUSED:  None.
 
DRAINS:  None.
 
SPECIMENS:  None. 
 
INDICATIONS:  The patient is a very pleasant (XX)-year-old female who is now one month status post subtotal gastrectomy for a stage III gastric carcinoma.  She was found to have positive node that is localized for which Dr. Doe has requested that we place a port for adjuvant chemotherapy.  The procedure risks, complications including but not limited to bleeding, infection, pneumothorax and underlying pneumothorax were explained to the patient and her daughter, who was present, and agreed to proceed.
 
DESCRIPTION OF OPERATION:  With the patient in the main operating room under adequate IV sedation and carefully monitored by anesthesia, Kefzol was given at the time of induction.  A small towel was placed in the intrascapular area.  Both arms were tucked at the side and adequately padded.  The entire upper chest, on both sides, including the neck and shoulder area were prepped with iodoform and draped in the usual sterile fashion.  The patient was placed in Trendelenburg position.  Attention was first directed to the left infraclavicular region.  This was anesthetized using 0.25 % Marcaine.  Here, using a standard percutaneous Seldinger technique, I was unable to identify the subclavian vein, and I opted to go on the right side. 
 
At this point, the right infraclavicular region was anesthetized using 0.25% Marcaine.  Here, using a standard percutaneous Seldinger technique, I was able to identify the right subclavian vein with no difficulty.  Blood was aspirated.  The guidewire was then placed through the needle, guided along the subclavian vein, superior vena cava at the atrium as confirmed by fluoroscopy.  Next, a small pocket was then fashioned just below the entrance of the guidewire.  Hemostasis was then obtained within this pocket where a 7.8 French pre-assembled Deltec ProPort was then placed within the pocket and secured.  A catheter was then tunneled up to the entrance of the guidewire.  The catheter was then cut to appropriate length and flushed using heparin saline.
 
At this point, a dilator with a peel-away sheath was placed over the guidewire.  The guidewire along with the dilator was subsequently removed.  The catheter tube was then placed with the peel-away sheath.  As the catheter was then guided down, the subclavian vein, superior vena cava-right atrial junction was confirmed by fluoroscopy.  Blood was aspirated from this catheter with no difficulty and this was then also flushed with heparin saline with no difficulty.  At this point, hemostasis was then obtained. 
 
The small incisions were approximated using #3-0 Vicryl.  The skin was approximated using running subcuticular #4-0 Monocryl.  Steri-Strips were applied to the wound.  Before placing the dressing, the catheter was accessed one more time with absolutely no difficulty, flushed again using heparin saline and sterile dressing was applied to the wound. 
 
The estimated blood loss was minimal and none was transfused.  No drains were placed.  Sponge and instrument counts were correct x2 at the end of the case.  The patient subsequently tolerated the procedure well and was then returned to her room in stable condition.
 
--------------------------------

OPERATION PERFORMED:  Laparoscopic cholecystectomy.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. Following induction of general anesthesia, the abdomen was prepped with Betadine and draped sterilely. This patient had received Zosyn preoperatively. A 1.5 cm incision was made at the lower border of the umbilicus, dissection carried down through the skin and subcutaneous tissue. The umbilical raphe was visualized and placed on upward traction. A transverse incision was then made at the base of the raphe and the abdomen thus directly entered. A Hasson trocar was introduced and the abdomen insufflated with carbon dioxide to about 12 to 13 mmHg pressure. The 0-degree laparoscope was then introduced and the gallbladder inspected. It was very distended and thick-walled with obvious acute cholecystitis changes about it. Additional trocars were then placed into position in the right lateral, the right subcostal, and the epigastric area. The gallbladder was unable to be grasped due to its distention; therefore, it was decompressed with a needle through the right subcostal port. Following this, the grasper in the right lateral port was used to close the opening where the aspiration had been performed and to place the gallbladder on upward traction. The infundibulum was then placed on outward traction and the edematous tissue about the tapering of the infundibulum was clearly teased away to identify the cystic duct. There appeared to be several stones impacted in the neck. The cystic duct was cleaned free of surrounding tissue and then triply clipped with the endoclips applier and divided. Likewise, the cystic artery which ran adjacent to this was triply clipped and divided. The gallbladder was then removed from the liver bed with the cautery device and blunt dissection. Once removed, it was placed in an EndoCatch bag and then retrieved and removed through the umbilical port under direct vision. Inspection of the operative area was then carried out again, and since there was some mild oozing in the gallbladder fossa, it was felt best to drain this area postoperatively. Therefore, a #10 Jackson-Pratt was placed into the abdomen in Morison pouch and brought out through the right lateral trocar site. All irrigant was removed and returns were clear. The patient was then placed back in the flat supine position instead of the head upward position and all returns were further aspirated from the irrigant. Carbon dioxide was evacuated and the ports removed under direct vision, with no evidence of any oozing. The fascia at the umbilical and epigastric areas was then closed with interrupted 2-0 Vicryl and all skin incisions with 5-0 subcuticular Monocryl and Steri-Strips. Sterile bandage was applied and the patient then awakened and returned to recovery in good condition.

--------------------------------

PROCEDURE PERFORMED:  Percutaneous kidney transplant biopsy.

DESCRIPTION OF PROCEDURE:  After informed written consent was obtained from the patient, he was taken to the ultrasound suite and placed in the supine position on the stretcher with the left side popped up slightly with towels for optimal exposure of the transplant. The kidney transplant was localized in the left iliac fossa with ultrasound and a point overlying the lower pole was marked on the skin. The area was then prepped with Betadine and covered with a sterile fenestrated drape. Lidocaine 1% was infiltrated at the mark superficially and then to less than 1 cm, as indicated by ultrasound, to the surface of the kidney. A small incision was made at the anesthetized site with a #11 blade. A 16 gauge Monopty biopsy gun was then introduced through the incision to a depth of less than 1 cm and fired. A core tissue was obtained and placed in 10% formalin. The procedure was repeated once more, again yielding a core tissue. It was divided between formalin and Michel's solution. The procedure was then terminated. Firm pressure was applied to the biopsy site after each pass including 5 minutes after the last pass. A Band-Aid was then placed over the incision. A final ultrasound scan showed no obvious evidence of hematoma. A pressure dressing was applied. The patient tolerated the procedure well. There were no apparent complications. He has been returned to the floor in satisfactory condition and orders have been written for frequent vital signs, hematocrit, exam parameters.

--------------------------------
 
DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSES:
1.  Cholelithiasis, probable acute cholecystitis.
2.  Elevated liver function tests.
 
POSTOPERATIVE DIAGNOSES:
1.  Acute cholecystitis.
2.  Elevated liver function tests.
 
OPERATIONS PERFORMED:
1.  Laparoscopic cholecystectomy.
2.  Intraoperative cholangiogram.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  General inhalation anesthesia.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
ESTIMATED BLOOD LOSS:  Minimal.
 
SPECIMEN:  Gallbladder.
 
INDICATIONS:  This is a (XX)-year-old Caucasian female with episodic epigastric abdominal pain x4 in the past one month.  No fever or chills.  Positive nausea, no vomiting, but she had one episode of hematemesis.  No diarrhea or constipation.  Positive gas, positive spicy food intolerance.  She is postpartum 11 weeks.  Apparently, the pain would seem to come and go, and she would be able to treat this with oral Pepcid. However, the last time, Pepcid did not seem to work.  The abdomen at this time is soft and nontender.  She did complain of epigastric pain that is episodic in nature.  White blood cell count is normal.  Hemoglobin is normal.  LFTs are elevated at 246 and 190.  Bilirubin is normal but alkaline phosphatase is elevated.  An ultrasound shows gallstones in the common bile duct, 5 mm, and fluid around the gallbladder.  An EGD just shows mild gastritis, not enough to really account for her pain.  Informed consent was obtained for surgery.
 
DESCRIPTION OF OPERATION:  The patient was taken back to the operating room and placed under general inhalation anesthesia.  The patient was sterilely prepped and draped in the usual fashion.  Orogastric tube was used to decompress the stomach.  Marcaine 0.5% with epinephrine was infiltrated into the skin as a local anesthetic.  A semilunar subumbilical incision was made with a scalpel, and dissection was progressed down to the umbilical fascia with hemostats.  Fascia was grasped between hemostats and incised with a scalpel.  Abdomen was entered bluntly.  Anchoring suture of #0 Vicryl was placed.  A Hasson trocar was placed in the abdomen.  The abdomen was insufflated with CO2 gas.  A 5-mm laparoscope was placed in the abdomen under direct visualization.  Three 5-mm ports were placed in the subxiphoid and right upper quadrant area.
 
Upon initial examination of the abdomen, there was noted to be moderate amount of omental fat that was noted to be fairly normal in nature.  Small and large intestines that were seen were noted to be normal.  There was noted to be some serosanguineous fluid inside the pelvis measuring approximately 30 mL.  This was suctioned out with a suction-irrigator.  We could only see a small amount of pelvic organs from this angle.  Fundus of the uterus was able to be seen, was noted to be fairly normal otherwise.  Liver appears to be fairly normal for a patient of her age.  Gallbladder is mildly thickened but did have a thickened cholecystoduodenal ligament with many adhesions in this area.  However, there were no adhesions on the gallbladder body or fundus of the gallbladder itself.  Stomach also appears to be normal.
 
The grasper was placed on the fundus of the gallbladder and used to retract the gallbladder up and over liver.  A second grasper was placed on the Hartmann's pouch and used to retract the gallbladder inferolaterally.  Using a Maryland dissector, blunt dissection, we were able to take down the cholecystoduodenal ligament.  Cystic artery and cystic duct were both isolated with blunt dissection.  The distal cystic duct was clipped once with an endoclip and cut partially on the proximal side.  A Ranfac cholangiocatheter was then placed in this area and held in place by a clip.  Using C-arm fluoroscopy, we were able to take 50:50 mixture of Conray.  We were able to do a cholangiogram of the common bile duct.  Common bile duct and left and right hepatic radicles filled readily along with readily spilling into the duodenum.  There was noted to be no filling defects inside the common bile duct suggestive of common duct stones.  The area was flushed once with normal saline, and another cholangiogram was performed just to be sure there was no evidence of any filling defects.
 
Cholangiocatheter was removed and then the proximal cystic duct was clipped twice proximally and ligated.  Cystic artery was clipped twice proximally and once distally and ligated.  Further dissection into this area shows no evidence of a posterior cystic vessel, and using argon beam coagulator, the gallbladder was dissected free from the liver bed.  After that was done, the gallbladder was retrieved through the umbilical port without any problems.
 
The area was irrigated with sterile saline, suctioned back until clear.  Any bleeding points stopped with electrocautery.  There was noted to be good hemostasis.  No evidence of any bowel injury.  The abdomen was desufflated.  The ports were removed.  The laparoscope was removed.  The umbilical fascia was approximated using figure-of-eight suture of #0 Vicryl, and the skin was approximated with #4-0 Monocryl in a subcuticular fashion.  Steri-Strips were applied over the incision site.  The patient tolerated the procedure well and was taken to PACU in stable condition.  All packs, instruments and needles were counted before this.
 

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Multinodular goiter, nonresponsive to medical treatment.

POSTOPERATIVE DIAGNOSES:
Multinodular goiter, nonresponsive to medical treatment, pending final pathology report.

OPERATION PERFORMED:
Total thyroidectomy.

SURGEON:  John Doe, MD

ANESTHESIA:
General endotracheal.

INDICATIONS FOR OPERATION:
The patient is a (XX)-year-old male who has undergone ultrasound of the thyroid, which showed multinodular goiter.  The patient was, up until this point, treated aggressively by the endocrinologist, but the patient has not responded.  Therefore, the patient was recommended thyroidectomy.  The patient has no history of radiation to the neck or family history of thyroid malignancy.  The procedure, risks and complications which include but are not limited to bleeding, infection and possibility of recurrent laryngeal nerve injury with secondary hoarseness, possibility of parathyroid injury with secondary hypoparathyroidism and recurrent calculi formation were thoroughly explained to the patient and he agreed to proceed.

OPERATIVE FINDINGS:
Diffusely enlarged thyroid.  No obvious and distinct nodules identified.  Both nerves very nicely identified and preserved.  Three parathyroids identified.

ESTIMATED BLOOD LOSS:
Minimal.

TRANSFUSIONS:
None.

DRAINS:

Two 7 mm flat Blake drains.

SPECIMEN:
Total thyroid.

DESCRIPTION OF OPERATION:
With the patient in the operating room, under adequate general endotracheal anesthesia, Kefzol was given at the time of induction.  A shoulder roll was placed and the neck was hyperextended.  The entire neck was prepped with iodoform and draped in the usual sterile fashion.  A cervical collar incision was made and carried through the subcutaneous tissues to the platysma; at this point, subplatysmal planes were established.  The midline cervical fascia was then incised, and at this point, the strap muscles were nicely elevated off the thyroid.  The middle thyroid was identified and transected using the Harmonic scalpel.  Attention was directed to the right upper lobe.  It extended quite high up into the cephalad part of the neck.  Using careful dissection, we were able to identify the pedicle quite nicely, extending quite nicely by separating from the strap muscles, clipping towards the patient's side and transecting with the Harmonic scalpel.  At this point, the parathyroid on this side was identified and preserved.  In a similar fashion, inferior pedicle was identified and transected using the Harmonic scalpel.  The recurrent nerve was very nicely identified through its trajectory.  The thyroid was then carefully removed off the tracheoesophageal groove.  Great care was taken to stay away from the recurrent laryngeal nerve and the thyroid was subsequently brought out into the midline, towards the Berry's ligament.  In a similar fashion, the left side was undertaken by again elevating the strap muscles from the thyroid.  The middle thyroid was transected using Harmonic scalpel.  The upper pole was again isolated, clipped and transected using the Harmonic scalpel.  In a similar fashion, inferior pedicle was again isolated and transected and clipped using the Harmonic scalpel.  Again, this was carefully dissected off the tracheoesophageal groove.  It should be noted that on the left side we were able to release and identify very nicely preserved two parathyroids. The thyroid was subsequently removed from the tracheoesophageal groove, again here identifying recurrent laryngeal nerve which were confirmed on both sides using nerve stimulators, confirmed they were both nice and intact.  The entire thyroid was subsequently removed.  The right upper lobe was then marked using white microsutures and sent to pathology.  At this point, hemostasis was then obtained.  Both nerves were again checked using nerve stimulator, found to be nice and intact with good impulses.  Three parathyroids have been identified and preserved.  Two 7 mm flat Blake drains were placed on each side of the fossa, secured to the skin using interrupted 3-0 Prolene.  The midline cervical fascia was approximated using running 3-0 PDS.  The platysma was approximated using running 3-0 Monocryl.  The skin was then approximated using wide staples.  Steri-Strips were applied in between the staples along with a sterile dressing.  Estimated blood loss was minimal.  None was transfused.  Two drains were placed, two 7 mm flat Blake drains.  Sponge, needle and instrument counts were correct on three occasions.  The patient subsequently tolerated the procedure well and was then returned to recovery room in very stable condition.

--------------------------------

DATE OF OPERATION:  MM/DD/YYYY
 
PREOPERATIVE DIAGNOSIS:  Acute appendicitis.
 
POSTOPERATIVE DIAGNOSIS:  Acute appendicitis.
 
OPERATION PERFORMED:  Laparoscopic open appendectomy.
 
SURGEON:  John Doe, MD
 
ASSISTANT:  None.
 
ANESTHESIA:  General.
 
ANESTHESIOLOGIST:  Jane Doe, MD
 
SPECIMEN REMOVED:  Appendix.
 
BLOOD LOSS:  Less than 50 mL.
 
FINDINGS:  The patient had acute appendicitis.  There was no evidence of pus in the peritoneal cavity and no evidence of perforation.
 
DESCRIPTION OF THE OPERATION:  With the patient supine on the table, the abdomen was prepped with Betadine and draped in a sterile manner.  A Rocky-Davis incision was made at McBurney’s point in the right lower quadrant of the abdomen.  The aponeurosis of the external oblique was divided in the direction of its fibers while the fibers of the internal oblique and transversus abdominis were divided and the peritoneum was opened.  The cecum and appendix were easily delivered through the incision.  The appendiceal blood vessels were cross-clamped, divided and tied with 3-0 Vicryl ties.  The base of the appendix was doubly ligated with 0 chromic and divided.  The peritoneum was thoroughly irrigated with normal saline.  The peritoneum was then closed with 0 Vicryl running locking sutures.  The fascia was approximated with 1 PDS running sutures.  The subcutaneous tissue was thoroughly irrigated with normal saline, and having obtained complete hemostasis, the skin was approximated with 4-0 Vicryl subcuticular sutures.  Steri-Strips and dressings were applied.  The patient went through the operation well and left the operating room in satisfactory condition.
 

Comments