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General Surgery Operative Medical Transcription Sample


DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:  Morbid obesity, hypertension, hypercholesterolemia, exertional dyspnea, arthritis, urinary frequency, and asthma.

POSTOPERATIVE DIAGNOSES:  Morbid obesity, hypertension, hypercholesterolemia, exertional dyspnea, arthritis, urinary frequency, and asthma.

OPERATIONS PERFORMED:  Laparoscopic Roux-en-Y gastric bypass with silastic ring and gastrostomy tube placement.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS: None.

ESTIMATED BLOOD : 125 mL.

SPECIMENS: None.

DRAINS: A 19 round Blake drain.

DESCRIPTION OF OPERATION: The patient was identified in the holding area and brought to the operating suite, where she was placed in the supine position and general endotracheal anesthesia was induced without complications. Her abdomen was then prepped and draped in the usual sterile fashion. Abdominal cavity was entered with an Optiview trocar. Next, two trocars were placed in the left side of the abdomen followed by three trocars in the right side of the abdomen, all under direct visualization. A liver retractor was inserted into the right lateral-most trocar site. The fat pad of the angle of His was excised, and the peritoneal reflection was opened at the angle of His. Next, a window was created into the lesser sac along the lesser curvature. A transverse divided staple line was then created 16 mm distal to the GE junction, perpendicular to the lesser curvature. Next, a vertical divided staple line was created from the transverse staple line up to the angle of His creating a 2.5 cm wide, completely dividing proximal gastric pouch. The staple line of the excluded stomach was then imbricated with Vicryl in a running fashion. Next, an anvil corresponding to a 21 circular stapler was placed into the distal aspect of the gastric pouch using a nasogastric tube in a transoral, transesophageal technique. A silastic ring of 6 cm in circumference was then fashioned around the distal portion of the gastric pouch just proximal to the anvil. Next, a Penrose drain was placed into the lesser sac. The ligament of Treitz was then identified. A window was created in the transverse mesocolon just above and to the left ligament of Treitz and one end of the Penrose drain retrieved through the window. The small bowel was measured for a distance of 30 cm from the ligament of Treitz and divided. This measured an additional 75 cm in the proximal device mobile stump, anastomosed to a 75 cm mark in a side-to-side, functional, end-to-end fashion.  The resulting enterotomy was closed with Vicryl in a running two-layer fashion. The mesenteric defect was closed with silk in a running fashion. The distal stump of the divided small bowel which represented the alimentary limb was brought retrocolic and retrogastric delay adjacent to the gastric pouch. A 21 circular stapler was then used to create an end gastric pouch to the side jejunal anastomoses. The redundant afferent stump of the alimentary limb was amputated with a stapler. A gastrojejunal anastomosis was reinforced with Vicryl in a running fashion. Next, the retrocolic window was closed to the alimentary limb in a running fashion. The upper abdomen was carefully irrigated and no evidence of oozing noted. A gastrostomy tube was then placed percutaneously through the anterior abdominal wall through a silastic ring to serve as a radiologic marker into the excluded stomach. The excluded stomach was tacked up to the anterior abdominal wall with silk in interrupted fashion. A 19 round Blake drain was then positioned adjacent to the gastric pouch. Liver retractor and all trocars were removed. The left side trocar site which was dilated to accommodate 21 circular staple was closed by reapproximating fascia with #0-Prolene. The remaining trocar sites were closed by reapproximating skin with #4-0 Vicryl. These were reinforced with Dermabond. The patient was then extubated and brought to postanesthesia care unit in stable condition.

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Acute appendicitis.

POSTOPERATIVE DIAGNOSIS:  Acute appendicitis.

PROCEDURE PERFORMED:  Laparoscopic appendectomy.

SURGEON:  John Doe, MD

DESCRIPTION OF PROCEDURE:  The patient was given general endotracheal anesthesia.  Foley catheter and sequential compression devices were placed.  The patient received antibiotics.  Pneumoperitoneum was established through an infraumbilical stab incision up to 15 mmHg pressure.  The incision was enlarged.  A 5 mm trocar cannula was inserted.  The patient was placed in the head down and to the left position.  The sacrum and small bowel were retracted superiorly and medially and findings revealed an acutely inflamed appendicitis.  There was no sign of any perforation.  The mesoappendix was visualized.  There was a band of mesentery surrounding the base of the appendix.  This had to be mobilized.  We took a while to mobilize it.  It could be band of Ladd.  This had to be divided.  We were still unable to see the base of the appendix.  Finally, there were some posterior and inferior adhesions to the retroperitoneum.  These also had to be divided and now we could see the base of the appendix.  The mesoappendix was then visualized and Endo GIA applied and transected.  There were some bleeders at the transected mesentery.  These were controlled by electrocautery as well as application of hemoclips.  There was an additional small mesenteric segment left and this was dissected, stapled with Endo GIA and divided.  Finally, the base of the appendix was very visible and well delineated.  The Endo GIA was applied and the appendix transected.  Hemostasis was checked and found to be satisfactory.  There was no additional bleeding.  Pelvis was irrigated copiously with normal saline.  Also, the fluid accumulated in the area of liver was suctioned out.  The patient was placed in a flattened position from a head down position and the bloody fluid gravitated to the right lower quadrant; this was suctioned out.  Extra care was taken to see if there was any more additional bleeding; none was noticed after observation.  The appendix was brought out and removed through the left lower quadrant stab wound and cannula.  The left lower quadrant was closed.  The rest was closed with subcuticular.  The procedure was well tolerated.  Estimated blood loss was less than 15 mL.