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Bilateral Open Orchiopexy Operative Sample Report / Example

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Right testicular torsion.

POSTOPERATIVE DIAGNOSIS:  Right testicular torsion.

PROCEDURE PERFORMED:  Bilateral open orchiopexy.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia via LMA.

COMPLICATIONS:  None.

DRAINS:  None.

ESTIMATED BLOOD LOSS: Minimal.

INDICATIONS FOR PROCEDURE:  This is a patient with a history of intermittent right-sided testicular torsion. Bilateral orchiopexy has been recommended and informed consent has been obtained.

DESCRIPTION OF PROCEDURE:  The patient was placed on the operating table in the supine position. General anesthesia was administered via LMA. The genitalia were sterilely prepped and draped in the usual fashion. A midline scrotal incision was carried down through the dartos layer. The tunica of the right testicle was opened and the testicle was examined. The right testicle was somewhat congested and inflamed. There were adhesions to the tunica. There was very scant hydrocele fluid present. The testicle had a normal position within the scrotum. A small appendix testis was removed and sent to pathology but appeared to be unremarkable and probably not a source of pain or torsion. The patient does demonstrate a bell clapper deformity consistent with possible torsion. The right testicle was pexed to the scrotal wall using three 2-0 chromic sutures in a triangle shape. The tunica was then closed with a running 3-0 chromic. The tunica of the left testicle was then opened. The left testicle appeared quite normal. There is a very small appendix testis, which was also removed. The left testicle was pexed to the scrotum using three 2-0 chromic sutures in a triangle fashion. The tunica of the left testicle was then closed with 3-0 chromic suture. Hemostasis was obtained when needed throughout the surgery with electrocautery. The dartos layer was reapproximated with a running 3-0 chromic. The skin was closed with a 2-0 chromic interrupted vertical mattress sutures. Polysporin ointment was applied followed by sterile dressings and a supporter. The patient tolerated the procedure well and was transported to the recovery room in satisfactory condition. Sponge and needle counts were correct x2.

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