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Exploratory Thoracotomy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Esophageal mass.

POSTOPERATIVE DIAGNOSIS:
Esophageal leiomyoma.

OPERATION PERFORMED:
1.  Exploratory right thoracotomy.
2.  Resection of benign esophageal leiomyoma.
3.  Intercostal nerve block with 0.25% Marcaine.

SURGEON:  John Doe, MD

CLINICAL SCRUB TECH:  Jane Doe, CST

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

CONDITION:  Stable to CVICU.

CHEST TUBES:  One straight 36 pleural tube.

FINDINGS:  Exploratory thoracotomy revealed a mass in the wall of the esophagus.  This was easily shelled out and sent off to Pathology for permanent and frozen section.  Frozen section revealed this 4 x 4 cm tumor to be a benign leiomyoma.

INDICATIONS FOR PROCEDURE:  The patient is a very pleasant (XX)-year-old Hispanic female with known history of chest pain.  The patient had a complete workup, including a CT scan which revealed a mass either in the esophagus or a paraesophageal mass.  She had esophagoscopy, which revealed a mass compressing on the right lateral border of the esophagus, but no intraluminal lesion.  The patient was taken to the operating room at this time for exploratory thoracotomy and resection of esophageal or paraesophageal mass.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, placed on the table in the supine position and placed under adequate general anesthesia.  She was intubated with a double-lumen endotracheal tube and turned to the left lateral decubitus position, then prepped and draped in the normal sterile fashion over the posterolateral chest wall.

A muscle-sparing incision was made for the posterolateral thoracotomy incision.  Both the latissimus and serratus muscles were mobilized and spared throughout the procedure.  The chest was entered through the right fifth interspace and retractors were inserted to gain adequate exposure.  The lung was deflated and then retracted posteriorly.  We then could easily locate the esophageal mass and it was easily palpable.  An NG was inserted into the esophagus, and with the NG in place, the mass was resected by simply shelling it out from the smooth wall of the esophagus.  The smooth muscle layers of the esophagus were then closed with interrupted silk sutures.  At no point during the procedure, did we actually enter the lumen of the esophagus.  Both air and sterile saline were injected into the esophagus through the NG tube.  There was no leakage of air or fluid at the site of resection.  Therefore, the area was irrigated copiously with the antibiotic saline solution.

A single chest tube was inserted through a separate stab wound and sewn to the skin.  The chest was then closed appropriately.  The wounds were dressed in a sterile manner.  Instrument counts and sponge counts were correct at the end of the procedure.  The patient tolerated the procedure well and was sent to the CVICU in stable condition.