Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Supracervical Hysterectomy RSO Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Pelvic mass, suspected fibroid, ovarian cyst.
2.  Anemia.

POSTOPERATIVE DIAGNOSES:
1.  Pelvic mass, suspected fibroid, ovarian cyst.
2.  Anemia.

PROCEDURES PERFORMED:
1.  Exam under anesthesia.
2.  Exploratory laparotomy.
3.  Right salpingo-oophorectomy.
4.  Supracervical hysterectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  275 mL.

INDICATION FOR PROCEDURE:  This is a (XX)-year-old multigravida female with four prior cesarean sections, who was noted to have anemia and an enlarged uterus compatible with fibroids and a possible right ovarian mass. Secondary to this, it was felt the above procedure was indicated, and the patient gave her informed consent for surgical management.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the supine position. She underwent general endotracheal intubation without complication. The patient was placed in the frog-leg position. An exam under anesthesia revealed a 14-16 week size anterior uterus that was irregular in shape. The patient was then prepped and draped in the usual fashion for the procedure. Thromboguards were placed on her lower extremities bilaterally, and a Foley catheter was anchored to closed gravity drainage.

The prior vertical skin scar/incision was sharply dissected and excised with scalpel. This incision was carried down to fascia with a deep knife. The fascia was incised in the midline and extended cephalad and caudad with Mayo scissors. The peritoneum was identified, elevated and entered with Metzenbaum scissors. Upon entering the peritoneal cavity, pelvic washings were obtained.

Examination of the upper abdominal cavity revealed a smooth liver edge and diaphragm. The lower poles of the kidneys were palpated and felt to be within normal limits. No retroperitoneal lymphadenopathy was noted. There was a 5 cm right adnexal cyst that appeared to be compatible with a dermoid or fibroma and a 16-week size uterus, which contained fibroids.

Hysterectomy was carried out by double clamping the round ligaments, excising with the scalpel and ligating with 0 Vicryl suture. The right anterior and posterior sheaths of the broad ligament were sharply incised with curved Mayo scissors and the retroperitoneal space developed with blunt dissection. The ureter was palpated. A rent was made superior to this in the posterior aspect of the broad ligament. The infundibulopelvic ligament was triply clamped and excised with the scalpel, ligated first with a free tie of 0 Vicryl suture followed by a modified figure-of-eight stitch. The uterine vessels were skeletonized. The left round ligament was doubly clamped and excised with the scalpel.

The anterior leaf of the broad ligament was incised sharply with Metzenbaum scissors. The retroperitoneal space was developed. She had a normal left tube and ovary. The round ligament, utero-ovarian ligament and fallopian tube were triply clamped and excised with a scalpel. The pedicle was ligated first with a free tie of 0 Vicryl suture followed by a modified figure-of-eight stitch. These uterine vessels were then skeletonized.

The cervicovesical space was then sharply developed. The uterosacral ligaments were doubly clamped with curved Heaney clamps. The pedicles were formed with the scalpel and ligated with 0 Vicryl sutures bilaterally. Hysterectomy was then carried out with straight Heaney clamps, forming the pedicles, excising them with the scalpel and ligating them with 0 Vicryl suture. Secondary to the depth of the pelvis and the length of the cervix, it was felt that a supracervical hysterectomy was indicated, and the cervix was then surgically amputated with both sharp and Bovie cautery. The angles were ligated in modified Heaney stitch fashion incorporating the uterosacral ligaments bilaterally. The cervix was then oversewn with figure-of-eight 0 Vicryl sutures. The specimen was handed off and sent to pathology for histopathologic confirmation.

Irrigation was used and hemostasis confirmed. The moist laparotomy sponges were removed. The parietal peritoneum was closed with running 3-0 Vicryl suture. Again, irrigation was used and hemostasis confirmed. The abdominal fascial edges were closed with interrupted 0 Vicryl sutures. Again, irrigation was used and hemostasis confirmed. The subcutaneous tissues were closed with interrupted 3-0 Vicryl sutures. An additional layer of a running subcuticular stitch was placed with 3-0 Vicryl suture, and the skin edges reapproximated with staples. A sterile dressing of Telfa and was applied.

 The patient was taken to the recovery room awake and alert and extubated. There were no intraoperative complications. The patient had Thromboguards on her lower extremities and a Foley catheter anchored to closed gravity drainage. The patient will have a PCA pump for postoperative analgesia.

MT Word Help      TAH Bilateral Salpingo-Oophorectomy     Medical Transcription Samples