Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Laparoscopic Appendectomy Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Acute appendicitis.

POSTOPERATIVE DIAGNOSIS:
Acute appendicitis.

OPERATION PERFORMED:
Laparoscopic appendectomy.

SURGEON:  John Doe, MD

ANESTHESIA:
General with endotracheal intubation.

COMPLICATIONS:
None.

BLOOD LOSS:
Minimal.

FLUIDS:
Crystalloid 1000 mL intraoperatively.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female who presented to the emergency room following approximately 6 hours of acute abdominal pain, which localized to her right lower quadrant. The patient underwent laboratory and x-ray studies, which had findings consistent with acute appendicitis. The patient now presents at this time for laparoscopic appendectomy.

DESCRIPTION OF OPERATION:  The patient was placed on the operating table in the supine position, and following induction of adequate general anesthesia, she was prepped and draped in the usual sterile fashion. Veress needle technique was used to insufflate the abdomen to 15 mmHg with carbon dioxide gas. A supraumbilical approach was taken. Once the abdomen was adequately insufflated, the Veress needle was replaced with a 5 mm blunt trocar placed under direct visualization. The abdomen was visually explored, and of note, there were adhesions between the area of the cecum and the anterolateral abdominal wall. No other gross abnormalities were readily identified. A 5 mm trocar was placed in the deep right pelvis and a 12 mm trocar was placed in the deep left pelvis.

The patient was placed in a mild Trendelenburg position and the adhesions were bluntly stripped from the anterior abdominal wall. The stiff and inflamed appendix was readily identified. It was curled upon itself, but after gentle dissection, it was able to be fully extended. There was no evidence of frank gangrene or perforation on initial visualization. Dissection with Maryland forceps and the base of the appendix created a tunnel between the appendix base and its mesoappendix. A 45 mm EndoGIA with a blue load was then fired across the base of the appendix to divide it. There were several attachments between the body of the appendix and cecum. These thin attachments were taken down with blunt and electrocautery dissection. Once the mesoappendix was freed, it was divided using the EndoGIA with a gray load.

At this point, the appendix was completely freed and it was removed from the abdomen in an EndoCatch pouch through the 12 mm trocar site. The surgical bed was then copiously irrigated with saline solution and all of the fluid was aspirated. The surgical staple line was then inspected and noted to be intact and hemostatic. The remainder of the surgical bed was irrigated and all the fluid was aspirated clear.

At this point, the procedure was terminated. Each trocar site was then infiltrated with a 50:50 mixture of 0.5% plain Marcaine and 1% plain Xylocaine. The 12 mm trocar site was then closed at the level of the anterior abdominal fascia using a 2-0 Vicryl with a figure-of-eight stitch. Each trocar site was then closed at the level of the skin using 4-0 Monocryl with a running subcuticular stitch. Benzoin, Steri-Strips, and sterile dressings were applied.

The patient tolerated the procedure well. She received approximately 1000 mL of crystalloid intraoperatively. Blood loss was minimal. There were no complications. Sponge, needle and instrument counts were noted to be correct. At this point, the patient was extubated in the operating suite and transported in hemodynamically stable condition to the PACU.