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General Surgery Medical Transcription Procedure Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Abdominal pain.

POSTOPERATIVE DIAGNOSIS: Mesenteric adenitis.

OPERATION PERFORMED: Laparoscopic appendectomy and exploration.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal and local, 0.5% Marcaine 1:1 with 1% lidocaine with epinephrine.

ANESTHESIOLOGIST:
Jean Doe, MD

ESTIMATED BLOOD LOSS: Less than 5 mL.

IV FLUIDS: 1000 mL lactated Ringer.

DRAINS: None.

COMPLICATIONS: None.

FINDINGS: Mesenteric adenitis, normal-appearing ovaries and fallopian tubes, and "boggy uterus."

DESCRIPTION OF OPERATION: After the patient was placed in a supine position, satisfactory general endotracheal anesthesia was obtained. The patient was sterilely prepped and draped in the usual fashion. A vertical incision was made in the infraumbilical region after infiltration with local anesthetic. The incision was made with a #15 blade scalpel. Dissection was then continued to the level of the fascia, which was further infiltrated with local anesthetic. It was sharply divided under direct visualization and isolated with #0 PDS.

The Hasson trocar was then introduced, again under direct visualization. The patient was then insufflated with 15 mmHg CO2. The patient was then placed in Trendelenburg. A Foley was previously placed, and the suprapubic 5-mm port was then introduced under direct visualization after infiltration of local anesthetic and an incision made by a #15 blade scalpel. The blunt dissectors were used to pull back the cecum.

The appendix was identified. The mesoappendix was noted to be markedly inflamed with lymphadenopathy. The right lateral 5-mm trocar was then introduced in an identical fashion. The ovaries were examined as well as the fallopian tubes and were found to be normal appearing. The uterus was noted to be slightly inflamed and boggy. There was fluid in the cul-de-sac.

The appendix was then retracted using a Babcock. The Maryland dissectors were used to create 2 windows in the mesoappendix allowing the vascular GIA stapling device to be introduced. It was fired and held after verifying position. The vascular pedicle was noted to be hemostatic. The remaining appendiceal stump was also treated in an identical fashion and found to be intact. The appendix was then placed in an EndoCatch bag, was removed in the usual fashion, and was sent to pathology for further evaluation. The area was copiously irrigated and aspirated. Hemostasis was confirmed. The trocar sites were further infiltrated with local anesthetic. The trocars were then removed under direct visualization and also noted to be hemostatic. The patient was then fully desufflated.

The fascia was closed using interrupted #0 PDS. All the wounds were irrigated. The skin margins were reapproximated using running #4-0 Monocryl subcuticular sutures. The wounds were then sterilely dressed. The patient tolerated the procedure well. She was resuscitated in the operating room and was transferred to recovery in a stable condition. All counts were correct. No complications.


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Biliary colic and abdominopelvic pain.

POSTOPERATIVE DIAGNOSES:
1.  Gallstones.
2.  Fibroid uterus.

OPERATION PERFORMED:
1.  Laparoscopic cholecystectomy.
2.  Laparoscopic appendectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

SPECIMENS:  Gallbladder and appendix.

DESCRIPTION OF OPERATION:  The patient was first given general endotracheal anesthesia and was then prepped and draped in the usual sterile fashion for laparoscopic cholecystectomy.  A transverse supraumbilical incision was made, and the abdomen was entered with a 5 mm port and then xiphoid 10 mm and two lateral 5 mm ports were placed.  The gallbladder was retracted superiorly and anteriorly.  The cystic duct and common duct were identified.  The cystic duct was triply clipped on the patient's side and singly clipped on the specimen side and transected.  The cystic artery was doubly clipped on the patient's side and singly clipped on the specimen side and transected.  The gallbladder was then removed from the liver bed with the Harmonic scalpel and placed in an EndoCatch device.  The patient was then placed in a Trendelenburg position.  Retrocecal appendix was identified.  This was mobilized at the wound with the Harmonic scalpel.  Once it was mobilized, the mesoappendix was divided with the Harmonic scalpel.  The base of the appendix was then ligated with 0-PDS sutures x2.  A third suture between the first and third was then placed.  The appendix was transected at the base between the first and third suture and then retracted out the 10 mm xiphoid port.  Examination of the pelvis revealed no sign of adhesions.  There was a markedly fibroid uterus and normal-appearing ovaries.  The port was then extended about a 10 mm area due to the marked size of the stones.  Once it was extracted, the 10 mm port was closed with interrupted 0 Vicryl on the fascia and then all four ports were closed with 4-0 Vicryl in subcuticular manner.