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Colonoscopy and Polypectomy Medical Transcription Operative Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Screening examination.

POSTOPERATIVE DIAGNOSIS:  Multiple colonic polyps.

OPERATION PERFORMED:  Total colonoscopy and multiple polypectomies including snare polypectomy.

ENDOSCOPIST:  John Doe, MD

ANESTHESIA:  IV fentanyl, Versed and Phenergan in incremental doses.

DESCRIPTION OF PROCEDURE:  Digital examination and inspection was normal.  The Olympus colonoscope was introduced into the rectum.  The scope was advanced without difficulty to the cecum.  The appendiceal orifice was identified.  There was stool inspissated within the appendiceal orifice.  Attempts were made to wash the stool out; this was unsuccessful.  The scope was gradually withdrawn.  In the proximal ascending colon, 3 polyps were noted, 2 were pedunculated, each removed using snare cautery.  They were retrieved and sent for histopathologic analysis.  The scope was reintroduced to this point.  Hemostasis was good.  There was a 4 mm sessile polyp, which was removed in multiple pieces and multiple passes using the cold biopsy forceps technique.  The scope continued to be withdrawn.

In the distal transverse colon, there were 5 colon polyps; 3 were removed using snare and cautery.  They were retrieved and sent for histopathologic analysis.  A 6 mm sessile polyp was removed using a hot biopsy forceps technique and a 4 mm sessile polyp was removed using the cold biopsy forceps technique.  The scope continued to be withdrawn.  At 70 cm from the anal verge, in what appeared to be the hepatic flexure, near the splenic flexure, 3 polyps ranging in size from 8 mm to 6 mm were removed by snare and cautery and retrieved and sent for histopathologic analysis.  At 50 cm from the anal verge, there were 4 colon polyps ranging in size from 1 cm to 3 mm in diameter.

Snare polypectomy was performed, and a cold biopsy forceps polypectomy was performed.  The tissue was retrieved and sent for histopathologic analysis.  Good hemostasis was observed after all cautery.  Toward the end of the procedure, it was noted that the patient had some diminutive polyps in the rectum; however, he was becoming restless and combative, although he was well sedated until this point.  It was felt that it was not prudent to proceed with removing these polyps at this moment.  It was felt, given the multiplicity of polyps and the multiple polypectomies, that this patient will require an early followup colonoscopy to make sure that all more proximal polyps are removed and, at that time, the diminutive rectal polyps could be removed.  The patient was brought to the recovery area in good condition.

PLAN:  Check biopsy results.  Assuming there is no unusual dysplasia, I will repeat the colonoscopy on this patient in 3 months to make sure all polyps are removed.  Then, longer intervals between colonoscopies will be recommended.