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General Surgery Medical Transcription Procedure Samples

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Biliary colic.

POSTOPERATIVE DIAGNOSIS: Biliary colic.

OPERATION PERFORMED: Laparoscopic cholecystectomy with liver biopsy.

SURGEON: First Name Last Name, MD

ASSISTANT: First Name Last Name, MD

ANESTHESIA: General endotracheal.

ANESTHESIOLOGIST: First Name Last Name, MD

ESTIMATED BLOOD LOSS: Minimal.

DESCRIPTION OF PROCEDURE: With the patient supine on the operating table, after induction of general endotracheal anesthesia, the abdomen was prepped and draped in the usual sterile fashion. An infraumbilical incision was made. Stay sutures were placed on the fascia. The fascia was opened and abdomen was entered. Hasson cannula was placed. CO2 was insufflated into the abdominal cavity. Laparoscope was placed. A midline port was placed, a midclavicular port was placed, and an anterior axillary port was placed. The gallbladder was taken down from above with the use of the Harmonic scalpel. Cystic artery was transected with the Harmonic scalpel. Cystic duct was ligated with the #0 PDS Endoloop. A 5-mm scope was placed in the upper midline port. Laparoscopic bag was placed in the Hasson, and the gallbladder was placed in the bag and deployed. A 10-mm scope was replaced in the Hasson. A wedge liver biopsy was taken with the Harmonic scalpel. A 5-mm scope was utilized in the upper midline port. A second laparoscopic bag was placed and opened. The liver biopsy was placed in the bag, and the bag was deployed. A 10-mm scope was replaced in the Hasson and the abdomen was irrigated copiously with saline solution, suctioned dry, and noted to be hemostatic. Trocars were removed. There was no bleeding. The Hasson was removed. Both bags were removed. The fascia and the umbilical port were closed with #0 Vicryl. The skin incisions were closed with #4-0 subcuticular Vicryl. Steri-Strips were applied. Dressings were applied. Counts were reported to be correct. Estimated blood loss was minimal. The patient tolerated the procedure well and left the operating room in a stable condition.

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic abdominal pain.
2.  Increased liver function tests, unclear etiology.

POSTOPERATIVE DIAGNOSES:
1.  Elevated liver function tests.
2.  Intestinal adhesions.

OPERATION PERFORMED:  Laparoscopic liver biopsy and lysis of adhesions.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

FINDINGS:  Normal-appearing liver. There was a single adhesion band crossing over the terminal ileum, which might have indeed been causing intermittent complete bowel obstruction from a prior appendectomy. There are no other intraperitoneal abnormalities noted. There was no mesenteric lymphadenopathy.

DESCRIPTION OF PROCEDURE:  The patient was first given general endotracheal anesthetic and was then prepped and draped in the usual sterile fashion for laparoscopy and possible laparotomy. A transverse supraumbilical incision was made.  Abdomen was entered with a 5 mm Optiview trocar. A 5 mm subxiphoid trocar was then placed. Examination of the peritoneal cavity revealed normal-appearing liver, but due to increased liver function tests, multiple core biopsies were obtained and sent for permanent specimen. Additionally, exploration of the peritoneal cavity revealed a normal-appearing pelvis. There were omental adhesions crossing over the distal terminal ileum, which might have indeed been causing complete obstruction. Additionally, there were numerous adhesions in the left upper abdomen, question whether this is due to prior inflammatory bowel disease or intra-abdominal vasculitis. These adhesions were lysed. The abdomen was irrigated. The prior biopsy site was cauterized extensively. There were no other intraperitoneal abnormalities noted. The patient tolerated the procedure well and was transferred back to recovery room in stable condition.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Immunodiffusion procedure.

POSTOPERATIVE DIAGNOSIS:  Immunodiffusion procedure.

OPERATIONS PERFORMED:
1.  Laparoscopic splenectomy.
2.  Distal pancreatectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  No complications.

FINDINGS:  Tail of pancreas was embedded in the hilum of the spleen; therefore, distal pancreatectomy was performed en bloc with the splenectomy.  There is no sign of accessory spleen.  There are no other gross intraperitoneal abnormalities noted, except for morbid obesity.

DESCRIPTION OF PROCEDURE:  The patient was first given general endotracheal anesthetic.  He was then prepped and draped in the usual sterile fashion of laparoscopic splenectomy.  A morbid obesity lap disc was placed in the epigastrium after infiltration of 0.5% Marcaine with epinephrine.  After this was performed, 5 mm and 12 mm left upper quadrant ports were then placed.  Short gastric vessels were transected with a Harmonic scalpel.  The splenic flexure of the colon was mobilized as well.  Once this was completed, the hilum of the spleen was noted to be densely adherent to the tail of the pancreas.  Therefore, the tail of the pancreas, splenic artery, and splenic vein were all transected with an Endocutter and stapler with use of Seamguards.  Once this was completely transected, the lateral attachments of the spleen were taken down with a Harmonic scalpel.  Spleen was then brought to the lap disc in one piece.  There was no abnormality noted.  The abdomen was then irrigated and 10 mm Jackson-Pratt was placed through the lateral 12 mm port since the distal pancreas was transected.  The patient tolerated the procedure well.  The lap disc was then closed with #1 Vicryl and 4-0 Vicryl in subcuticular manner.  Drain was sutured to the skin with 2-0 nylon.

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