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Urology Medical Transcription Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Left renal mass.

POSTOPERATIVE DIAGNOSIS: Left renal mass.

OPERATION PERFORMED: Left hand-assisted laparoscopic radical nephrectomy.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General.

ANESTHESIOLOGIST: Jean Doe, MD

DETAILS OF OPERATION: After the patient was given anesthesia, she was prepped and draped in the right-side-down decubitus position. All pressure points were padded. A Foley catheter had been inserted. The patient’s midline had been previously marked and approximately a 7 cm upper midline incision was made after local anesthesia was infused. The fascia was divided in the midline. A Lap Disc device was placed. Pneumoperitoneum was created using CO2, and under direct vision, the left lower quadrant was inspected. There were no abdominal adhesions. Two 10 mm trocars were placed lateral to the umbilicus on the left side. These were placed with the surgeon’s hand in the field. Local anesthetic had also been placed of 1% lidocaine and 0.25% Marcaine.

Using the Harmonic scalpel, the left colon was reflected along the white line of Toldt. There was a paucity of fat around the left kidney. Splenic attachments were removed. There was a small capsular tear, which was not bleeding. This was cauterized using the Harmonic scalpel, and at the termination of the case, there was no bleeding from this area and it was packed with Surgicel. The colon was reflected medially. The plane was created. The vein was identified. The surrounding vein attachments were taken down using the suction irrigation device as well as the Harmonic scalpel.

The ureter was then identified, and the ureter was clipped with 2 large clips proximally and distally and divided using scissors. The kidney was retracted and lifted. The posterolateral attachments of the kidney and surrounding fat were taken down. Again, there was a paucity of fat around this kidney. The posterior attachments of the kidney were further freed and the kidney was mobilized. This then allowed further identification of the renal vein. The single renal vein had a single renal artery directly posterior and superior to this. The kidney was further mobilized. The artery was separated using suction irrigation device as well as Maryland dissector. This was then divided using the vascular Endo-GIA stapling device. The vein was then divided in a similar fashion lateral to the left gonadal and adrenal veins. The kidney was then further mobilized along the upper pole. An attempt was made to perform an adrenal sparing procedure. These segments were divided using the Harmonic scalpel. The remaining posterior upper pole attachments were also divided using the Harmonic scalpel.

Kidney was then completely freed. A Cook specimen bag was placed through the hand port, and the kidney was placed in this bag and removed through the hand port in the specimen bag. Reinspection of the surgical field revealed no bleeding from the spleen, artery, vein or left lower pelvis. Two pieces of Gelfoam were placed in the fossa and the colon was reflected laterally.

The patient’s midline fascia was closed using running loop #1 PDS x2. The ports and hand port sites were all closed with a running subcuticular 4-0 Vicryl suture.

Prior to the skin closure, an On-Q percutaneous anesthetic drain was placed through a separate stab incision. The drain was secured in the correct place and was filled with 0.5% Marcaine.

The patient tolerated the above procedure well. She had Steri-Strips placed and was taken to the recovery room in a stable condition. The kidney was sent for pathologic evaluation.


DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Gross hematuria.

POSTOPERATIVE DIAGNOSIS:  Gross hematuria secondary to recurrent prostate cancer.

OPERATION PERFORMED:  Cystoscopy, bladder biopsy.

SURGEON:  John Doe, MD

OPERATIVE FINDINGS:  Mild meatal stenosis, but otherwise normal urethra up to the level of the membranous urethra.  This area was involved with recurrent irregular prostate cancer, which also involved the trigone, obscuring the ureteral orifices.  A sample was obtained for pathology.

DESCRIPTION OF PROCEDURE:  After the patient obtained an adequate general anesthesia, he was placed in the dorsal lithotomy position.  His genitals were prepped with Betadine and draped with sterile drapes.  His meatus was dilated using Van Buren sounds.  A 21 French cystoscope was placed in the bladder under direct vision.  The bladder neck was fixed and the above-mentioned irregular prostate cancer tissue was noted.  A sample was removed for pathologic evaluation.  There was no sign of obvious transitional cell malignancy.  Small amount of residual clot was irrigated from the bladder and cystoscopy was completed.  We elected not to fulgurate any areas, as there was not any one dominant bleeding area, and further manipulation would likely result in more bleeding.  The cystocope was removed, and an 18 French Foley catheter was placed with light pink return.  The patient tolerated the procedure well and was transported to the recovery room in satisfactory condition.