Esophagogastroduodenoscopy with Esophageal Variceal Band Ligation Medical Transcription Procedure Sample Report

REFERRING PHYSICIAN:  John Doe, MD

PROCEDURE PERFORMED:  Esophagogastroduodenoscopy with esophageal variceal band ligation.

INDICATION:  Hematemesis.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained and conscious sedation was achieved with Demerol and Versed. Total sedation used was 75 mg of Demerol and 7 mg of Versed. The patient tolerated the procedure well. The patient was placed in left lateral position and video EGD scope was introduced into the hypopharynx and advanced under direct vision up to the second portion of the duodenum without difficulty.

PROCEDURE FINDINGS:
1.  The distal esophagus showed evidence of large esophageal varices with some of them having red wale sign indicating recent hemorrhage and also high risk for re-bleeding.
2.  Stomach showed evidence of erosive gastritis, but no active bleeding.
3.  The duodenum was normal.

The endoscope was withdrawn and a Saeed Six Shooter band ligation device was placed at the tip of the endoscope and the endoscope was reintroduced. Six bands were placed at different columns, specifically targeting the areas of red wale signs. The band ligation was successful. However, since there were significant varices, a total of ten bands were placed using another Saeed Six Shooter band ligation device.

DIAGNOSES:
1.  Esophageal varices with signs of recent hemorrhage, high risk for re-bleeding.
2.  Erosive gastritis.

RECOMMENDATIONS:
1.  Continue proton pump inhibitors.
2.  Start nadolol 40 mg a day.
3.  See the patient in the office in about two weeks.
4.  The patient will need a repeat upper endoscopy and band ligation in about three weeks.

Thank you, Dr. Doe, for the opportunity to participate in this patient’s care.

Medical Transcription Samples

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites

Vascular Surgery Operative MT Sample Report - Aortogram with Bilateral Lower Leg Extremity Runoff

PREOPERATIVE DIAGNOSIS:  Bilateral lower extremity rest pain, left worse than right.

POSTOPERATIVE DIAGNOSIS:  Bilateral lower extremity rest pain, left worse than right.

PROCEDURE PERFORMED:  Aortogram with bilateral lower leg extremity runoff.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with sedation.

IV FLUIDS:  650 mL.

ESTIMATED BLOOD LOSS:  Minimal.

URINE OUTPUT:  175 mL.

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  Using the SonoSite and under ultrasound guidance, we placed a 4-French sheath via Seldinger technique to the right common femoral artery. A catheter was inserted into the aorta and an aortogram was performed.

AORTOGRAM:
The visualized portions of the celiac and SMA arteries are patent, the orifices were not individually interrogated. There appears to be bilateral single renal arteries that are widely patent. The aortic bifurcation appears normal.

The Omni Flush catheter was then placed in the aortic bifurcation and a runoff was performed. The results of the angiogram are as follows.

RIGHT-SIDED ANGIOGRAM:
The right common iliac artery is widely patent as is the right external iliac artery. The right internal iliac artery is opacified faintly but is patent and of very small caliber. The right common femoral artery is normal. The profunda appears normal. The origin of the superficial femoral artery appears mildly diseased with some posterior plaque. Approximately 10 cm distal to the origin of the SFA, there is a high-grade stenosis, approximately 80%. There are multiple minimal areas of narrowing, no greater than 20%, diffusely along the superficial femoral artery. Once the SFA enters the adductor canal, the popliteal artery is widely patent to the below-knee popliteal artery. The anterior tibial artery origin appears normal. The tibioperoneal trunk origin appears normal. However, shortly after takeoff, the anterior tibial artery and the tibioperoneal trunk occlude. In the mid leg, the peroneal and posterior tibial artery reconstitute. The peroneal artery is patent and bifurcates just above the ankle as expected. The posterior tibial artery is the main runoff to the foot and forms the plantar arch.

LEFT LOWER EXTREMITY ANGIOGRAM:
The common femoral artery is widely patent. The origin of the profunda and superficial femoral artery appear widely patent. The profunda is a well-developed vessel. The superficial femoral artery, however, is a short segment though diffusely diseased along its length. Approximately 10 cm past the origin of the SFA, there is an approximately 60% stenosis of the SFA that is no longer than 1 cm long. There is another high-grade stenosis short segment just proximally to the adductor canal. There are multiple collaterals arising just proximal to the stenosis. This is approximately 80% stenosed. The above and below knee popliteal arteries are widely patent. The anterior tibial artery is not visualized. The tibioperoneal trunk is occluded. There does appear to be reconstitution of the peroneal artery at the mid leg. The posterior to the artery does reconstitute approximately two-thirds the way down the leg. This enters below the ankle joint, but there is not a clearly defined plantar arch.

Next, the Omni Flush catheter was selectively placed in the proximal SFA and contrast injections of the left leg were performed. Again, geniculate collaterals reconstitute the peroneal artery at the mid tibial level. Distally, in the distal one-third of the tibia, the posterior tibial artery reconstitutes. The peroneal artery is patent where it bifurcates just above the ankle. On the selective shots, it does appear that the posterior tibial artery does form the plantar arch nicely.

Next, an angiogram of the right lower extremity, semiselective, was performed with contrast injections through the right 4-French sheath. This revealed basically a normal caliber popliteal artery to the takeoff of the anterior tibial artery and beginning of the tibioperoneal trunk. However, both of these occlude shortly thereafter. Further shots of the foot are not able to be obtained due to difficulties and timing of the contrast bolus through the ipsilateral sheath. Therefore, this was the end of the procedure. The patient tolerated the procedure well.


Cardiac Catheterization and PCI Transcription Sample Report

DATE OF STUDY:  MM/DD/YYYY

 PROCEDURES PERFORMED:
1.  Cardiac catheterization.
2.  Percutaneous coronary intervention.

 DESCRIPTION OF PROCEDURE:  The patient was prepped and draped in a sterile manner and locally anesthetized with 2% lidocaine to the right femoral artery area. JL4 and JR4 diagnostic catheters were used for the diagnostic portions of the procedure. All catheters were aspirated and flushed prior to their use. All catheters were advanced under fluoroscopic guidance over a guidewire and retracted over a guidewire.

A 6-French sheath was placed in a retrograde manner in the right femoral artery over a guidewire and it was aspirated and flushed. A JR4 catheter engaged the right coronary artery and injection revealed a normal right coronary artery with two stents in the mid aspect of the right coronary artery, which were widely patent. There were only minor luminal irregularities in the remaining right coronary artery circulation. The right posterior descending is small and unremarkable. The right posterolateral branch is unremarkable.

A JL4 catheter engaged the left main coronary artery. Injection revealed normal left main coronary artery. The left circumflex and its branches appeared to be angiographically unremarkable. The mid LAD beyond the first diagonal branch had a 40% diffuse stenosis, which was eccentric in nature. The LAD coursed around the apex of the left ventricle. The first diagonal branch had 80% proximal stenosis and 80% mid vessel stenosis. This first diagonal branch appeared to provide blood supply to a substantial portion of the lateral wall of the left ventricle.

It was elected to proceed with PCI. Angiomax was given per protocol. The patient was already receiving Plavix for the previously placed stents. The 5-French diagnostic catheter was exchanged for 6-French JL5 angioplasty guiding catheter. A 190 BMW guidewire was advanced beyond the serial 80% stenosis at the proximal and mid diagonal of the first diagonal branch coronary artery.

A 2.25 x 12 mm Voyager balloon was inflated into the distal 80% lesion to 8 atmospheres up to 25 seconds. TIMI III blood flow. There was some element of spasm at this wound site with a residual 60% stenosis. Then, the balloon was retracted to the proximal 80% stenosis and another inflation occurred to 9 atmospheres at the proximal lesion. This lasted for 25 seconds. The balloon was deflated. There is a residual 50% narrowing at that region.

Next, it was elected to stent the distal region first. Consideration was given to drug-eluting stent but was stopped at this portion of the mid distal artery, as it was smaller in caliber than that which would accommodate a drug-eluting stent. As a result, a 2.25 x 12 mm Mini-Vision stent was deployed in the distal 80% lesion with a residual 60% lesion after balloon angioplasty. This stent was deployed at 14 atmospheres x30 seconds. There was TIMI III blood flow at this site. There was no evidence of dissection at this site. There was no dye extravasation.

Next, a Cypher drug-eluting stent was placed proximally in the proximal diagonal 50% residual stenosis. A 2.5 x 13 Cypher drug-eluting stent was paced there and inflated to 12 atmospheres x40 seconds. There was TIMI III blood flow in the diagonal branch artery. The proximal lesion was reduced to 0% residual stenosis with no dissection or dye extravasation. All angioplasty hardware removed and the patient was in good condition at the close of the procedure.

CONCLUSIONS:
1.  Patent right coronary artery stents previously placed. These stents were evaluated with diagnostic angiography because the patient re-presented with atrial fibrillation, which was converted with drugs.
2.  Successful PTCA and stenting of two lesions in the first diagonal branch of the coronary artery with the distal lesion ultimately stented with a 2.25 x 12 mm Mini-Vision stent with 0% residual stenosis. The more proximal lesion was stented with a 2.5 x 13 Cypher drug-eluting stent with 0% residual stenosis at that site. It was noted that the patient has 40% narrowing, which is diffuse in the mid LAD.

PLAN:
1.  A 30-minute infusion of Angiomax.
2.  Plavix 300 mg will be given.
3.  Antilipidemic agents will be increased with atorvastatin being increased to 80 mg upon discharge.
4.  The patient will be hydrated and monitored on telemetry.

General Surgery Medical Transcription Sample - Carotid Endarterectomy

PREOPERATIVE DIAGNOSIS:  Right internal carotid artery stenosis, 90%. 

POSTOPERATIVE DIAGNOSIS:  Right internal carotid artery stenosis, 90%. 

OPERATION PERFORMED:  Right carotid endarterectomy with Hemashield patch graft. 

SURGEON:  John Doe, MD 

ANESTHESIA:  General. 

ESTIMATED BLOOD LOSS:  Minimal. 

COMPLICATIONS:  None. 

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in supine position. After general anesthesia was given, the skin of the right neck was prepped with DuraPrep and draped in a sterile fashion. The right neck was explored through an incision along the anterior border of the sternocleidomastoid muscle. An incision was made through the subcutaneous tissue, platysma divided, bleeders controlled with electrocautery. The fascial veins and lingual veins were divided and ligated with 2-0 black silk. The common carotid, internal and external carotid arteries, as well as the superior thyroid artery were isolated with vessel loops. The patient was heparinized, given 7000 units of heparin. Internal, external carotid arteries were clamped. Arteriotomy made in the common carotid artery extending to the internal, endarterectomy of these vessels were performed. The arteriotomy was repaired with a Hemashield patch graft with a continuous 6-0 Prolene suture material. The clamps were released. Circulation established to the external and internal carotid artery. The patient was given 75 mg of protamine sulfate. The patient had diffuse bleeding to the suture line and a few interrupted sutures were placed to control the bleeding until this was under control. The area was irrigated with antibiotic solution. The platysma was closed with continuous 2-0 Vicryl and the skin closed with subcuticular 4-0 Vicryl and a sterile dressing was applied. The patient tolerated the procedure well and was sent to recovery in stable condition.

Exploratory Laparotomy with Colectomy Medical Transcription Sample Report

PREOPERATIVE DIAGNOSIS:  Inflammatory phlegmon in the right lower quadrant.

POSTOPERATIVE DIAGNOSIS:  Inflammatory phlegmon in the right lower quadrant, likely secondary to perforated cecal diverticulitis.

OPERATION PERFORMED:  Exploratory laparotomy through a right lower quadrant incision with a right colectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  500 mL.

COMPLICATIONS:  None apparent.

DRAINS:  Jackson-Pratt x2.

SPECIMENS:  Right colectomy.

DESCRIPTION OF OPERATION:  After informed consent was obtained from the patient and after the possible operative risks, complications, and alternatives were discussed, he was taken to the operating room and placed on the operating table in the supine position. Anesthesia was induced. The patient was intubated. The abdomen was shaved and prepped with Betadine and draped sterilely. A transverse incision was made in the right lower quadrant. The incision was deepened with electrocautery. The fascia was entered, the muscle fibers were split, the peritoneum was entered, and retractors were placed on the wound. The cecum was obviously severely inflamed with a large inflammatory phlegmon. It was impossible to mobilize without extending the incision and dividing the abdominal wall musculature. A self-retaining retractor was assembled and used to maintain retraction of the abdominal wall for better visualization. The inflammatory phlegmon was rather massive and involved the ileocolic mesentery and the right paracolic gutter extending into the pelvis. The appendix was located in this but was not clearly the source of this. There was a large abscess that was freely draining pus from posteriorly and this appeared to be adjacent to the cecum and not necessarily arising from the appendix itself.

The etiology was thought to be most likely cecal diverticulitis. Regardless, a wide resection with right colectomy was indicated. The terminal ileum was divided with a GIA stapler, including in the resection specimen a small portion of the terminal ileum at the ileocecal valve that was indurated and inflamed. The mesentery to the ileocecal area was divided with LigaSure with good hemostasis. The right colon was mobilized along the right paracolic gutter. There was some difficulty with the fixation due to the phlegmon and mobilizing the hepatic flexure. Ultimately, the transverse colon was divided in its proximal portion, and working backward using LigaSure, it could be divided from its omental attachments, gastrocolic attachments, and its mesentery. When the specimen was entirely free, it was forwarded to pathology. The transverse colon was seen to reach easily to the terminal ileum. Both segments of bowel were grossly normal at this area, healthy and viable. The mesenteric defect was approximated with PDS suture. The bowel ends were placed in approximation with PDS suture and a stapled side-to-side functional end-to-end anastomosis was accomplished with the GIA stapler. The defect created by the stapler and anastomosis was closed in two layers with 3-0 Vicryl and interrupted 3-0 PDS Lembert sutures.

The wound was irrigated and the irrigant suctioned out. Sponge, needle, and instrument counts were correct. Inspection for hemostasis showed that there was still a small amount of oozing along the right paracolic gutter, particularly at the site of mobilization of the hepatic flexure. There was no pulsatile bleeding, just a small amount of oozing. Two 10 flat Jackson-Pratt drains were left, the superior most placed along the right paracolic gutter extending up to the region of the hepatic flexure and the second placed in the lower retroperitoneum at the site of abscess. These exited through separate stab incisions and were secured in place at the skin site with silk sutures. The wound was irrigated and the irrigant suctioned out. Again, sponge, needle, and instrument counts were correct, and the fascia was closed with a deep layer of running #1 Vicryl and more superficial layer of running #1 PDS. The subcuticular tissues were irrigated and skin edges were approximated with skin staples. A sterile dressing was applied. The patient was awakened and returned to recovery in stable condition.

Medical Transcription Samples

Dental Surgery Medical Transcription Transcribed Procedure Sample Report

PREOPERATIVE DIAGNOSIS:  Severe dental caries and infection.

POSTOPERATIVE DIAGNOSIS:  Severe dental caries and infection.

PROCEDURE PERFORMED:  Dental restorations, extractions and impressions.

SURGEON:  John Doe, DMD

ASSISTANT:  Jane Doe

DESCRIPTION OF PROCEDURE:  The patient was taken to the OR and induced with nitrous oxide oxygen and sevoflurane. An IV was started in the left hand. The patient was intubated through the right naris and was maintained on nitrous oxide oxygen and sevoflurane. Sterile drapes were placed in the usual manner. The patient's oropharynx and mouth were irrigated and thoroughly suctioned. A thin moist throat pack was placed.

Teeth #3, 14 and 19 were restored with pit and fissure sealants. Tooth #30 was restored with an OB composite restoration. Teeth #A and J were restored with OL composite restorations. Teeth #K and T were restored with OB composite restorations. Teeth #B and L were restored with stainless steel crown cemented with Ketac. Tooth #S was restored with a formocresol pulpotomy and a stainless steel crown was cemented with Ketac. Tooth #I was restored with an occlusal composite restoration. Teeth #M, Q and R were extracted without difficulty. Gelfoam was placed in the extraction sockets. Two 4-0 gut sutures were placed. Teeth #K and T were fitted with stainless steel bands and impressions were taken for fabrication of a lingual arch holding appliance. Hemorrhage was easily controlled. Estimated blood loss was minimal. Throat pack was removed.

The patient was extubated in the operating room and taken to the recovery room. The patient's condition was good during the recovery period. The prognosis for retention of the remaining dentition is good. The patient is to be discharged with instructions including activity, diet, medications; diet being liquid, may proceed with soft diet at dinner if the patient tolerates. The patient is to be seen in my office in one week for postoperative evaluation.

More Dental Surgery Sample Reports                  MT Word Help

Cystoscopy and Cystolitholapaxy Medical Transcription Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Left renal calculi.

POSTOPERATIVE DIAGNOSES:
1.  Left renal calculi.
2.  Urethral calculus.

OPERATIONS PERFORMED:
1.  Cystoscopy - through suprapubic sinus.
2.  Left ureteral stent placement.
3.  Cystolitholapaxy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

DRAINS:  None.

SPECIMENS REMOVED:  Urethral/bladder calculus (1 x 2.6 cm).

TUBES:  Foley, 24-French.

ESTIMATED BLOOD LOSS:  Zero.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was brought to the cystoscopy suite by the OR and anesthesia staff and put on the cystoscopy table. The patient was gently induced with anesthesia and intubated without difficulty. The patient was then brought down to the edge of the cystoscopy table and placed in dorsal lithotomy position. His peritoneum and lower abdomen were prepped and draped in a sterile fashion. His suprapubic catheter, which was a 24-French catheter, was removed. At this point, a 21-French rigid cystoscope was passed, with a 30-degree lens, through the suprapubic sinus easily into the bladder. The bladder was systematically inspected and showed some chronic inflammatory changes due to chronic indwelling suprapubic tube. His ureteral orifices were identified bilaterally and were in normal anatomic configuration.

At this point, we followed the trigone down into the prostatic fossa where the verumontanum was identified. There was also a large urethral/bladder calculus approximately 1 x 2.6 cm sitting in the prostatic fossa. On later examination with the 70-degree scope, it was seen that there was no outside communication of the urethra to the external genitalia, and that the urethra must have been tied off at some point in the past. Attention was then turned to the left ureteral orifice. A 0.035 inch Glidewire was attempted to be passed through the cystoscope into the left ureteral orifice. This was unsuccessful, as the angle was difficult through the suprapubic sinus. At this point, an angled Glidewire was tried, which was also unsuccessful. We then tried an angled, tapered 5-French catheter and this was successful in entering the ureteral orifice and was passed through this up into the left renal pelvis under direct visualization and fluoroscopic guidance. Using the push-pull technique, the angled, tapered catheter was removed over the wire and a 6-French x 24 cm left ureteral stent was placed. The wire was removed and a curl was seen in the renal pelvis under fluoroscopic guidance and under direct visualization in the bladder.

Our attention was then turned to the bladder/urethral calculus. The rigid cystoscope was removed and a stone crusher was used to break up the stone into multiple small pieces. The stone was quite easy to crush. The stone crusher was then removed and an Ellik bulb suction device was used to attempt to remove these fragments, however, this was unsuccessful due to the angle. A glass Toomey syringe was then used to barbotage and attempt removal of the stone fragments. This was also unsuccessful. At this point, we used a spaghetti suction catheter to suction the stone fragments through the sheath of the cystoscope and this was successful for the most part. There were some residual stone fragments, but they were small and insignificant. Minimal irritation was caused and there were no active bleeders identified. At this point, the scope was removed and a 24-French Foley catheter was replaced in the bladder. The patient's urine was clear to pink after the procedure was over and draining well. The patient was transitioned to the PACU after being successfully extubated in stable condition.

Insertion of Inflatable Penile Prosthesis Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Organic erectile dysfunction.

POSTOPERATIVE DIAGNOSIS:  Organic erectile dysfunction.

PROCEDURE PERFORMED:  Insertion of inflatable penile prosthesis.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  65 mL.

COMPLICATIONS:  None.

DESCRIPTION OF PROCEDURE:  Following induction of general anesthesia, the patient was shaved and skin prepped for 10 minutes with iodine scrub followed by Betadine paint. The patient was draped in a sterile fashion including U drape and previous dressing between the legs, which were placed in frog-leg position. A sub penoscrotal incision was made with sharp dissection carried through the dartos muscle with Lone Star retractor placed with double rings, large above and small below. The transverse Deaver retractor was positioned at the base of the penis and the Foley catheter was inserted into the bladder with some difficulty, requiring downsize to a 16 French catheter. Once the catheter was in position in the bladder, a hook was placed on the inside of the dorsal aspect of the meatus and the penis drawn cephalad over the transverse retractor. The penoscrotal incision was deepened and hooks were used to retract the skin superior to inferior and to either side. The corpora cavernosa was dissected free of surrounding adventitial tissue on the patient's left, and the soft tissues were then retracted to the patient's right, allowing exposure of the contralateral corpora cavernosa.

Once exposure was achieved, stay sutures of 0 PDS suture were placed in each corpora x2 and a vertical incision was placed between corpora extending approximately 2-3 cm in length. Metzenbaum scissors was passed distally and then proximally into the corpora on either side with the points of the scissors hugging the internal aspect of the corpora cavernosa, tunica albuginea. Next, Hegar dilators were positioned proximal and distal with gradual increase in dilator size to 13. Once dilation was complete, the corpora were irrigated with antibiotic solution consisting of vancomycin and gentamicin. The assembly was prepared on the back table, including the Ambicor inflatable penile prosthesis and pump. The corpora cavernosa were measured at 19 cm total with 10 cm distal and 9 cm proximal. We chose a 15 cm prosthesis with 4 cm extensions and 12 mm caliber. The Furlow insertion device was then positioned with a Keith needle and positioned to position the distal end of the prosthesis through the glans penis. This was performed on each side and the proximal prosthesis was then inserted into the proximal corpora cavernosa.

Once the prosthesis was seated, the tubing was cleared of air and the rubber-shod clamp removed allowing inflation of the prosthesis to assure that there was no kinking or cross-over of the prosthesis. Once we were assured of this, the prosthesis was then emptied and the tubing re-clamped while the stay sutures were tied transversely to close the corpora cavernosa. The Lone Star retractor was removed and a subdartos pocket was identified and created with insertion of gauze soaked in 1% lidocaine with epinephrine. A 65 mL reservoir was then cycled with water and emptied. The external ring was traversed with the index finger of the left hand and a Deaver retractor was positioned, retracting the external oblique fascia of the external ring cephalad and Metzenbaum scissors then punctured through the transversalis fascia into the retroperitoneal space. A finger created space within the retroperitoneal tissues and the reservoir was positioned in the retropubic space and filled with 65 mL of saline.

The pump was then positioned in the subdartos pocket and the tubing between the reservoir and the pump was clamped with rubber shods and excess tubing was cut. The connecting device was then placed and the crimper was used to secure connection between the reservoir and the pump. The prosthesis was cycled, showing again good evidence of erection without kinking or aneurysm. The corpora cavernosa cylinders were left at approximately 70% filled and the subdartos tissues were closed over the pump, which was secured in the anterior-inferior aspect of the scrotum. The Lone Star retractor was replaced with retractors extending the transverse penoscrotal incision to either side and a round Blake drain was placed through a separate stab incision into the subdartos space adjacent to the tunica vaginalis.

The dartos and skin were closed in one layer with interrupted 3-0 chromic sutures, and upon completion of skin closure, a fluff gauze dressing with Telfa was placed over the incision and a stretch tape dressing was placed over the scrotum, first vertical and then transverse. The Foley catheter was taped to the anterior abdominal wall and the Blake drain attached to a vacuum bulb. The patient was then transferred to the recovery room in satisfactory condition. 

Labels: , ,

General Surgery Medical Transcription Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Esophageal achalasia.

POSTOPERATIVE DIAGNOSIS:  Esophageal achalasia.

OPERATIONS PERFORMED:
1.  Laparoscopic Heller cardiomyotomy.
2.  Laparoscopic Toupet fundoplication.
3.  Intraoperative esophagogastroduodenoscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  50 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was transported to the operating room and placed supine on the operating table. Following induction of satisfactory general endotracheal anesthesia, the patient was placed in a dorsal lithotomy position using Allen stirrups with appropriate padding of all pressure points. The abdomen was then prepped and draped in the usual fashion using Betadine solution and sterile towels and sheets. A skin incision was made approximately 8 cm inferior to the xiphoid process, superior to the umbilicus and to the left of the midline. The dissection was carried down to the level of the anterior fascia and the abdominal cavity entered under direct vision using an Optiview trocar. Carbon dioxide gas was instilled and a satisfactory pneumoperitoneum was achieved without evidence of respiratory compromise. The 30 degree laparoscope with video camera was threaded through this trocar site and the upper abdomen explored.

Examination of the right upper quadrant revealed a normal-appearing gallbladder and liver without nodularity over the surface. The anterior serosal surface of the stomach was unremarkable and there was no evidence of splenomegaly. Having completed the exploration, a 10 mm trocar was placed along the left costal margin at the midclavicular line and a 5 mm trocar placed on the left costal margin at the anterior axillary line. Two additional 5 mm trocars were placed in the subxiphoid position as well as in the right upper quadrant lateral to the rectus musculature. The 5 mm liver retractor was introduced through the right upper quadrant trocar site and used to elevate the left lobe of the liver. This allowed for complete exposure of the esophageal hiatus. There was no evidence of a sliding axial hiatal hernia and there was a moderate amount of inflammation surrounding the distal esophagus from the patient's prior dilatation.

The gastrohepatic ligament was initially opened over the caudate lobe of the liver using the Harmonic shears. The hepatic branch of the vagus nerve was identified and preserved. The peritoneal incisions were extended over the left and right crus and the mediastinum entered. The esophagus was then circumferentially mobilized and the anterior and posterior vagal nerve trunks identified. The posterior nerve trunk was left in place along the posterior wall of the esophagus and the distal aspect of the anterior trunk completely mobilized. The nerve trunk was encircled with a vessel loop, secured in place with an 0 PDS Endoloop. The posterior aspect of the gastroesophageal junction was fully mobilized as well and a pediatric Penrose drain passed around the esophagus at this level. This was secured in place with an 0 PDS Endoloop. The lesser sac was then entered along the greater curvature of the stomach inferior to the inferior pole of the spleen. The short gastric vessels were divided with the Harmonic shears to the level of the left crus and care was taken to ensure that the entire posterior aspect of the upper fundus of the stomach was completely mobilized.

Next, attention was turned to performing the cardiomyotomy. A site was selected along the anterior wall of the cardia of the stomach, at least 3 cm inferior to the gastroesophageal junction. The serosa and muscular wall of the stomach were then divided using Bovie electrocautery and Harmonic shears, exposing the mucosa of the stomach. Care was taken to ensure that the mucosa was not violated and that all the circular muscle fibers of His were divided. The myotomy was then extended over the anterior wall of the esophagus, carefully dividing the circular and longitudinal muscle fibers. Using the Harmonic shears, the myotomy was extended at least 8 to 10 cm proximally to the dilated area of esophagus where the muscular wall was no longer thickened. Again, care was taken to ensure that the esophageal mucosa was carefully preserved and the muscular wall of the esophagus was widely separated.

Intraoperative esophagogastroduodenoscopy was then performed and confirmed an adequate myotomy extending down onto the wall of the stomach without evidence of injury of the esophageal mucosa. The stomach and esophagus were desufflated and the scope removed. The vessel loop was removed from the anterior vagus nerve and attention turned to reapproximation of the crus posteriorly. This was accomplished using felt pledgets and a single horizontal mattress suture of 0 Ethibond. Care was taken to ensure that there was no narrowing of the esophageal hiatus or anterior angulation of the esophagus. Next, the posterior aspect of the upper fundus of the stomach was passed posteriorly to the esophagus. The esophagus appeared to lie comfortably within the bed of the fundus and there was no evidence of tension. The posterior aspect of the fundus was then secured to the diaphragm using 2-0 Ethibond sutures. The Toupet fundoplication was completed using 2-0 Ethibond sutures as well. The superior sutures were placed at the 10 o'clock and 2 o'clock positions between the muscular wall of the esophagus, the fundus of the stomach, and the diaphragm. Two additional sutures were placed on either side between the muscular wall of the esophagus and the fundus of the stomach.

At the completion of the fundoplication, it measured approximately 2.5 cm in length and there was no evidence of tension. There was wide distraction of the myotomy exposing the esophageal mucosa and the area of dissection was thoroughly irrigated with Kantrex solution. After assuring satisfactory hemostasis, any remaining fluid was evacuated and the suction irrigator used to remove as much carbon dioxide gas as possible. The trocars were removed and the incisions irrigated with Kantrex solution. The fascial opening at the 10 mm trocar sites were closed with 0 Vicryl sutures and 0.5% Marcaine instilled into the incisions. The skin was closed with 4-0 Vicryl subcuticular suture and benzoin and Steri-Strips, as well as a Tegaderm dressing placed across the incisions. The patient was then awakened and transported back to the recovery room in satisfactory condition with sponge and needle counts reported as correct at the end of the procedure.

Subscribe to: Posts (Atom)