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Ob-Gyn Medical Transcription Operative Procedure Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Symptomatic leiomyomatous uterus.

POSTOPERATIVE DIAGNOSES:
1.  Symptomatic leiomyomatous uterus.
2.  Pelvic endometriosis.
3.  Dense right adnexal adhesions.

OPERATIONS PERFORMED:
1.  Laparoscopic-assisted vaginal hysterectomy with right salpingo-oophorectomy.
2.  Lysis of adhesions.
3.  Ablation of pelvic endometriosis.

SURGEON:  John Doe, MD

ANESTHESIA:  General with endotracheal intubation.

ANESTHESIOLOGIST:  Jane Doe, MD

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  150 mL.

DRAINS:  Foley catheter to bladder.

SPECIMENS:  Cervix, uterus and fibroids, morcellated, right fallopian tube and ovary.

DESCRIPTION OF OPERATION:  The patient was brought to the operating suite in stable condition. Informed consent had been obtained. Risks have been outlined. The patient was aware of the risks of surgery including but not limited to stroke, embolus, phlebitis, pain, infection, hemorrhage, heart, lung, and anesthesia complications as well as injury to the internal organs such as the bowel, bladder, blood vessels, nerves, kidneys, ureters and pelvic organs. She was aware she could form adhesions postoperatively, which could result in chronic pain or even obstruction of loop of bowel or a ureter. The patient had received intravenous prophylactic antibiotics. She is aware of the options to the surgical procedure. She was aware this is a permanent sterilizing procedure. She had antiembolic stockings and pneumatics in place in the lower extremities.

The patient was placed under general endotracheal anesthesia and positioned in the modified lithotomy position in adjustable Allen stirrups. The abdomen, perineum and vagina were prepped and draped in standard fashion for the laparoscopic-assisted vaginal hysterectomy. An indwelling catheter was placed in the bladder. Pelvic examination was performed which revealed a retroverted, irregular, mobile uterus, size of an 8- to 10-week gestation, consistent with fibroids. Sponge stick was placed into the posterior vaginal fornix for manipulation purposes. This was found to be adequate and we really had to utilize the sponge stick and certainly did not require placing a more traumatic elevator.  After infiltration of the area with Marcaine and epinephrine solution, incision was made in the navel through which the Veress needle was placed with care into the peritoneal cavity.  After saline drop test, a pneumoperitoneum was created with 1.9 liters of carbon dioxide with normal filling pressures to 7 to 8 mmHg. The needle was then withdrawn. A 5 mm clear bladeless laparoscopic trocar sleeve with laparoscope inserter was then advanced under direct visualization with video camera assistance through the umbilical incision into the abdominal cavity, after elevation of the anterior abdominal wall. The laparoscope was advanced and inspection was commenced. Two right and left suprapubic incisions were made well medial to the epigastric vessels, in a hemostatic fashion, again after infiltration of the regions with the Marcaine and epinephrine solution, two additional blunt 5 mm laparoscopic trocar sleeves were passed under direct intraperitoneal visualization with the laparoscope. Blunt grasping forceps and the 5 mm ACE curved shears attached to the Harmonic scalpel were passed through the lower ports initially. Inspection was performed with the findings as noted above. Representative photographs were obtained.

Attention was turned initially to proceeding with adhesiolysis. The mild left adhesions were lysed with Harmonic scalpel. Care was taken to proceed with a more careful adhesiolysis procedure involving the right tube and ovary. Right ovary was teased off the pelvic sidewall where it was adhered primarily in a blunt fashion. Implants of endometriosis were coagulated with the Harmonic scalpel. There were some raw surfaces left on the sidewall, but this seemed to be in the region of the ureter; therefore, we did not proceed with an extensive dissection and removal of this region. Carefully, at the end of the procedure, this area was reinspected and was noted to be hemostatic. There were no obviously visible implants of endometriosis remaining at the end of the procedure. At this point, tube and ovary had freed up and attention was turned to performing the laparoscopic portion of the surgical procedure. Initially, the right uterine pedicles were taken. The tube and ovary were retracted medially and the ovarian vessel pedicle was carefully grasped, coagulated and transected. The dissection was then carried across the upper broad ligament tissues, round ligament and lower broad ligament tissues. The leaves of the broad ligament were bluntly separated at the site of the lower uterine segment. An incision was made anteriorly to the peritoneum and the vesicouterine fold. The bladder was then bluntly dissected down towards the cervix. Hydrodissection with a suction irrigator was utilized as well. The ascending branches of the uterine artery were identified. These were carefully coagulated with the Harmonic scalpel along with bipolar cautery forceps. Inspection at this point revealed excellent hemostasis except for some back bleeding coming from the right ovary. This was controlled with Harmonic scalpel and bipolar cautery forceps. A suction irrigator was passed to irrigate the operative area and aspirate out the bloody fluid.

Attention was turned to the left uterine pedicles. The dissection was carried initially across to the utero-ovarian ligament and vessels so that the ovary was conserved. Dissection again was performed with the Harmonic scalpel. The proximal fallopian tube was then taken followed by the round ligament and broad ligament tissues. Again, the ascending branches of the uterine artery were identified, skeletonized, grasped and coagulated with the Harmonic scalpel and also with bipolar cautery forceps. At this point, the pneumoperitoneum was released and inspection was performed to assure hemostasis of all pedicles prior to turning vaginally. Some clear fluid was left in the pelvis. A Deaver retractor and weighted speculum were placed into the vagina. The cervix was grasped with a Jacobs clamp. The mucosa of the cervicovaginal junction was then injected circumferentially with the Marcaine and epinephrine solution. With curved Mayo scissors, an incision was made through the midline, posterior vaginal mucosa, peritoneum and the posterior cul-de-sac. The weighted speculum with a long narrow blade was then repositioned into the peritoneal cavity. With the scalpel, incision was made anteriorly from the mucosa to the cervicovaginal junction. With blunt and sharp dissection, the bladder was dissected off the cervix. The anterior cul-de-sac was ultimately reached and a Deaver retractor was placed to gently elevate the bladder anteriorly. Curved Z-clamps were utilized to take the remaining pedicles. Initially, the uterosacral and cardinal ligament complex was clamped, transected, Heaney suture-ligated with 0 Vicryl sutures and then tagged. The uterine vessels were clamped, transected and suture-ligated with 0 Vicryl sutures. Broad ligament tissue was grasped, clamped, transected and suture-ligated.

Once the uterus had been totally freed up by inspection and digital examination, attention was turned to removal. The uterus was too large to be removed intact. Therefore, a careful morcellation procedure was performed by pouring out central portions including the cervix and mid-fundal region. Some fibroids also were isolated and removed. A combination of sharp dissection with the scalpel and Jorgenson scissors was utilized. Ultimately, the specimen was delivered through the vagina and handed off the operative field. Inspection of all pedicles was performed at this point to assure hemostasis. Some oozing around the right uterine artery was controlled with further 0 Vicryl sutures. Inspection was performed at this point to assure hemostasis. After inspecting for several minutes, attention was turned to closure of the peritoneum and the pelvic floor. Prior to this, clots and blood were evacuated from the pelvis with a sponge stick. A pursestring suture of 0 Vicryl was placed to close the peritoneum and the pelvic floor. The uterosacral and cardinal ligaments were then anchored to the apices of the vagina with intraoperative figure-of-eight sutures of 0 Vicryl. The pubocervical and rectovaginal fascias at the vaginal apex were reapproximated with several 0 Vicryl sutures. The vaginal mucosa was then closed with 0 Vicryl sutures. Inspection of the vaginal cuff for several minutes was performed and excellent hemostasis was noted. A sponge stick was placed.

The laparoscope was reinserted and a pneumoperitoneum was re-created. The bipolar cautery forceps and suction irrigator were passed and inspection of the pelvis was performed. Peritoneal lavage was performed. All bloody fluid and clots were evacuated from the peritoneal cavity. Couple of small oozing points were controlled with bipolar electrocautery. The pneumoperitoneum was released at this point for several minutes under minimal pressures. The pedicles and the pelvis were carefully inspected to assure hemostasis. Excellent hemostasis was noted. We had also carefully inspected to assure there were no remaining visible implants of endometriosis that required ablation. At the end of the procedure, approximately 50 mL of clear irrigation fluid was left in the pelvis. The laparoscopic instruments were removed. The three incisions were closed with 4-0 Vicryl deep and subcuticular skin sutures followed by Steri-Strips. The patient was awakened, extubated and returned to the recovery room in stable condition. The instrument, sponge and needle counts were reported as correct. Estimated blood loss was 150 mL. There were no complications.

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