Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Laparoscopic Adhesiolysis Medical Transcription Operative Sample Report

PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. History of previous pelvic surgery and ovarian cyst.

POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. History of previous pelvic surgery and ovarian cyst.

OPERATION PERFORMED:  Laparoscopic adhesiolysis.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

URINE OUTPUT:  75 mL.

IV FLUIDS:  850 mL.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was taken to the operating room. She was placed in the dorsal supine position and general anesthesia was induced. The patient was then placed in dorsal lithotomy position in Allen stirrups and prepped and draped in the normal sterile fashion. A Foley catheter was placed to gravity. Speculum was placed in the posterior and anterior vagina and the cervix was grasped with a single-toothed tenaculum. A Hulka clamp was then inserted through the cervix into the uterus for uterine manipulation. The tenaculum was removed and attention was then turned to the abdomen.

A supraumbilical incision was made with a scalpel and elevated up with towel clamps. A long Veress needle was then placed and CO2 gas was used to insufflate the abdomen and pelvis. A 10-12 trocar and sleeve were then placed and intraabdominal placement was confirmed via the 0 degree laparoscope. Immediately, the dense omental adhesions to the anterior abdominal wall were noted. At this time, we were able to see into the pelvic region. A second trocar and sleeve were placed in the left mid quadrant under direct visualization. The size of this port was 5 mm. The ligature device was then placed developing a plane between the omentum and the anterior abdominal wall.

The adhesiolysis took place and it took approximately 30 minutes to get down all of the omental adhesions from the anterior abdominal wall. We were then able to visualize the pelvis and a blunt probe was placed through the port. The ovary was visualized and photos were taken. There was no evidence of any ovarian cyst or ovarian pathology. There was no evidence of pelvic endometriosis. The uterus also appeared normal and the left tube and ovary were surgically absent. The appendix was easily visualized and noted to be noninflamed, normal in appearance, and there were no adhesions in the right lower quadrant. The upper abdominal exam was unremarkable. A decision was made to conclude the procedure at this point. The ports were removed. CO2 gas was allowed to escape. The incisions were closed with 4-0 Vicryl suture. The Hulka clamp was removed. The vagina was noted to be hemostatic. The patient's anesthesia was reversed, the Foley catheter was removed, and she was taken in stable condition to the postoperative recovery room.


Medical Transcription Samples