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Septoplasty Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSES:
1.  Nasal obstruction.
2.  Septal deviation.

POSTOPERATIVE DIAGNOSES:
1.  Nasal obstruction.
2.  Septal deviation.

OPERATION PERFORMED:  Septoplasty.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  Less than 20 mL.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old woman with a remote history of nasal trauma, who now presents for left-sided nasal obstruction.  The patient was found on physical examination to have a deviated septum.  It was felt that the patient would benefit from straightening the septum to increase ease of breathing, and the patient was taken to the operating room to correct this issue.

DETAILS OF PROCEDURE:  After informed consent was obtained, the patient was brought to the operating room and placed on the table in the supine position.  Once a suitable plane of anesthesia was obtained, the patient was endotracheally intubated by anesthesia personnel.  Afrin-soaked nasal pledgets were instilled into the nasal cavity bilaterally.  After decongestion, 1% lidocaine with 1:100,000 epinephrine was injected into the left septum to aid with hydrodissection as well as hemostasis.  Local was injected into the right nasal septum at the level of the bony-cartilaginous junction.

Next, the patient was prepped and draped in the standard fashion. A hemitransfixion incision was made in the left anterior nasal vestibule.  Care was taken not to injure the nasal sill.  Using a combination of sharp and blunt dissection, a mucoperichondrial flap was elevated on the left side beyond the deviated cartilaginous septum and just posterior to the bony-cartilaginous junction. The cartilaginous septum was found to be convex to the left side just anterior to the bony-cartilaginous junction. The septal cartilage was then disarticulated from the perpendicular plate of the ethmoid and vomer, and a mucoperichondrial flap was elevated on the right side, fully exposing the bony septum.

Care was taken to get all the mucosa off of the bony septum before removing the bony septum with rongeur forceps. After removal of the perpendicular plate of the ethmoid and some tissue of the vomer, the nasal cavity was reinspected and the septal deviation was corrected. Flaps were inspected and the right-sided flap was intact. On the left side, there was a small rent less than 2 mm on the inferior aspect of the mucoperichondrial flap. The bilateral nasal cavity passages were adequately opened, and the remaining cartilaginous septum was found to be left in the midline.

The anterior hemitransfixion incision was then closed with interrupted 4-0 chromic, and a quilting suture was placed through the flaps to lessen the dead space with 4-0 plain gut. At this point Afrin-soaked nasal pledgets were placed in the bilateral nasal cavities. The nasopharynx was suctioned of any blood, and care was turned over to Anesthesia for extubation. The patient was successfully extubated in the operating room and stable upon transfer to the postanesthesia care unit. Afrin pledgets were removed in the postanesthesia care unit prior to discharge.


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