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Uvulopharyngopalatoplasty and Tonsillectomy Medical Transcription Transcribed Surgical Sample Report / Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:  Respiratory insufficiency, obstructive sleep apnea and chronic tonsillitis.

POSTOPERATIVE DIAGNOSES:  Respiratory insufficiency, obstructive sleep apnea and chronic tonsillitis.

OPERATION PERFORMED:  Uvulopharyngopalatoplasty and tonsillectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ANESTHESIOLOGIST:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Approximately 350 mL.

DRAINS:  None.

COMPLICATIONS:  None.

SPECIMENS:  A portion of the palate as well as the right and left tonsils.

INDICATIONS:  The patient is a (XX)-year-old male with a history of recurrent sore throats with at least one to two episodes per month over the last year and also increasing difficulties breathing while sleeping.  The patient was eventually diagnosed as having obstructive sleep apnea; however, he was unable to tolerate the use of a CPAP apparatus as well as oral appliances.  Regarding the recurrent sore throat, they were believed to be in part due to the obstructive sleep apnea as well as to chronic tonsillitis.  On examination of the oral cavity and the oropharynx, the oropharyngeal tissues were redundant with an elongated posteriorly tethered palate and markedly enlarged tonsils that were +3 to +4 in size bilaterally and were cryptic with entrapped debris.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room and placed on the OR table in supine position.  After adequate general endotracheal anesthesia, the patient was prepped and draped in the usual fashion.  The Crowe-Davis mouth gag was inserted into the oral cavity without difficulties.  The palate was examined and palpated.  A point was identified in the palate where the posterior surface came into contact easily with the posterior pharyngeal wall.  At this point, mucosal incision was made with the use of the Harmonic scalpel.  The mucosal incision was carried laterally toward the superior tonsillar fossa, both the right and left side, also using the Harmonic scalpel.  At the superior tonsillar fossa, the mucosal incisions were turned at 90-degree angles and carried inferiorly along the anterior tonsillar pillars to the base of the tongue on both the right and left side using the Harmonic scalpel.  The uvula was then grasped with a clamp and retracted inferiorly.  A mucosal incision was then made along the superior border of the posterior tonsillar pillar in a diagonal fashion, angled toward the superior tonsillar fossa, on both the right and left side.

Once the posterior tonsillar pillars were divided, the palate was then transected at a 45-degree angle.  With the palate transected, a mucosal flap was developed from the palate where vertical incisions were extended superiorly just lateral to the point of attachment of the previously resected uvula, with a mucosal flap developed from the palate itself as well as from the posterior tonsillar pillars.  These mucosal flaps were then swung laterally almost in a Z-plasty fashion towards the superior tonsillar fossa.  Although there was marked improvement in the elevation of the palate, there was still narrowing due to the markedly enlarged tonsils.  In view of the history of chronic tonsillitis and the cryptic nature of the tonsils, it was decided that the tonsils would also be removed.  The right tonsil was then grasped at the superior pole with a tenaculum and retracted medially.  The previously made mucosal incision through the anterior tonsillar pillar was continued down into the tonsillar fossa with the tonsil being dissected free of the fossa with a Harmonic scalpel as well as suction cautery.  The left tonsil was then grasped at the superior pole with a tenaculum and retracted medially.  The previously made mucosal incision through the anterior tonsillar pillar was continued down into the tonsillar fossa using the Harmonic scalpel.  The tonsil was then completely dissected free of the fossa with the Harmonic scalpel as well as with the suction cautery.  Along the inferior border of the left tonsil, at the base of the tongue, a large bleeder was encountered.  Multiple attempts at suturing the bleeder were difficult with the bleeder eventually being sutured with interrupted suture ligatures of 2-0 Vicryl.

With adequate hemostasis, the oral cavity was then irrigated with copious amounts of normal saline solution.  The previously developed flaps from the palate as well as from the posterior tonsillar pillars were then taken and swung laterally and sutured to the remaining mucosa along the superior border of the superior aspect of the tonsil, on both the right and left side, using multiple interrupted sutures of 2-0 Vicryl.  The remaining mucosa from the nasal surface of the palate was then taken and sutured to the remaining mucosa along the oral surface of the palate, also using multiple interrupted sutures of 2-0 Vicryl.  The remaining mucosa from the posterior tonsillar pillars was then taken and sutured anteriorly to the remaining mucosa along the anterior tonsillar pillar, on both the right and left side, using multiple interrupted sutures of 2-0 Vicryl.  The oral cavity and oropharynx once again were irrigated with copious amounts of normal saline solution.  The Crowe-Davis mouth gag was then released and removed with the patient being extubated in the operating room.  Having tolerated the procedure well, the patient was transported to the recovery room in stable condition.

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