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Shoulder Surgery Operative Sample Report / Transcription Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Labrum tear of the right shoulder with articular-sided rotator cuff tear.

POSTOPERATIVE DIAGNOSIS:  Labrum tear of the right shoulder with articular-sided rotator cuff tear.

OPERATION PERFORMED:
1.  Right shoulder arthroscopy with repair of anterior and posterior labrum using 4 Mitek Lupine suture anchors and repair of articular-sided rotator cuff tear.
2.  Subacromial decompression.
3.  Insertion of a pain pump.

SURGEON:  John Doe, MD 

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General with interscalene block.

IV FLUIDS:  1800 mL.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

SPECIMENS:  None.

DESCRIPTION OF OPERATION:  The patient was seen in the preoperative holding area and the correct operative site was identified. He was given interscalene block by Anesthesia. The patient was then transported to the operative suite, placed supine on the operating table, and given general anesthetic without difficulty. He was then placed into the left lateral decubitus position and an axillary roll was applied. The right upper extremity was suspended with 10 pounds in the T-bar suspension unit. The right shoulder was prepped with DuraPrep solution and draped in the usual sterile manner. The posterior portal was established. The arthroscope was placed into the joint. The patient had grade 3 and 4 chondromalacia of the glenoid. There was cartilage damage down to bone on the posterior glenoid. There was grade 3 chondromalacia of the articular humeral head. There was obvious evidence for large amount of labral tearing from posterior to superior to anterior. Biceps tendon itself was intact. There was articular surface rotator cuff partial tearing noted, which was extensive. Posterior capsular insertion was intact. Axillary recess was normal. Inferior glenoid labrum and inferior-posterior glenoid labrum was intact. The labrum did appear to be torn from the 9 o'clock position superiorly and the anterior portion of the labrum was torn off the bone to approximately at 3 o'clock position. Subscapularis tendon was intact.

An anterior-superior portal was established. The labrum was probed to confirm the presence of a tear. The glenoid was then prepared for repair. A combination of a tissue elevator, arthroscopic rasp, and an arthroscopic shaver were used to decorticate the medial glenoid from 9 o'clock to 3 o'clock position. Two Mitek Lupine suture anchors were placed posteriorly in the glenoid and anterior to the biceps tendon. These anchors were placed approximately at the 9 o'clock, 11 o'clock, 1 o'clock, and 3 o'clock positions. The labrum was looped with a single stitch and arthroscopic knot was tied, and the labrum was attached firmly to bone using standard technique. When that was complete, the inner surface rotator cuff tear was debrided. A partial articular-sided tear was noted. There was delamination of the undersurface with retraction. It was noted that this needed to be repaired. Using a spinal needle for guidance, the insertion of the supraspinatus on the greater tuberosity was located. The shaver was used to decorticate the bone just medial to the area of the suture anchor placement.

An arthroscopic shaver was utilized to make a small hole in the rotator cuff distally. A 5 mm titanium corkscrew anchor was placed into the greater tuberosity. The arthroscope was placed into the subacromial space, and subacromial decompression and debridement was performed just prior to placement of this anchor to help with visualization of the sutures. A straight bur, deep penetrator was then used to penetrate the superior portion of the rotator cuff, grab the inferior retractor portion and grasped the sutures from the suture anchor. This was done twice creating a mattress-type stitch. It was tied superiorly while watching the joint. Good approximation of the inferior portion of the rotator cuff tear to the greater tuberosity was seen. When that was completed, the final repair was visualized from the superior surface and that was found to be tied tightly down to the cuff tissue at the greater tuberosity. Under direct visualization, an angiocatheter was placed into the subacromial space.

All instruments were removed. Excess fluid and debris were removed. Portal sites were closed with nylon sutures. Marcaine 0.25% with epinephrine was bolused into the angiocatheter and the pain pump catheter was then placed through the angiocatheter. The pain pump was assembled and attached to the skin. A sterile dressing was applied. An ABD pad was placed over the dressing. The right upper extremity was placed into an UltraSling. The patient was returned to the supine position and general anesthetic was reversed without difficulty. The patient was transferred supine to the operative gurney and transported to the postanesthesia care unit in stable condition.