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Bilateral Vasectomy Varicocelectomy Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left varicocele, left spermatocele, and elective sterility.

POSTOPERATIVE DIAGNOSIS:
Not dictated.

OPERATION PERFORMED:
Bilateral vasectomy, left varicocelectomy, and left spermatocelectomy.

SURGEON:
John Doe, MD

ASSISTANT:
None.

ANESTHESIA:
General LMA.


ANESTHESIOLOGIST:
Jane Doe, MD

DESCRIPTION OF OPERATION:  After informed consent had been obtained, the patient was given general laryngeal mask airway anesthesia.  The patient was prepped appropriately giving access to the left inguinal area and scrotum.  After this, the local was placed in the left inguinal, after being draped in aseptic fashion, 0.5% Marcaine with epinephrine was infused into the left inguinal area.  Marcaine 0.5% plain was injected into the median raphe and to the left cord.

Then, the puncture scissors were used in order to open up the median raphe, and using the ring forceps, the vas was brought into the surgical field; it was dissected out.  Once it was dissected out, it was transected and ligated appropriately, and the segment was handed off for pathological identification.  The cords were tied proximally and distally x2 with #3-0 silk, and the tips were fulgurated.  Then, this site was closed with #4-0 chromic.

Then, incision was made in the left inguinal area, just at the external ring.  The cord was dissected out.  The testicle was brought to the surgical field and the tunica vaginalis was opened.  The complex cyst on the gland, on the globus major, was then dissected off, the area was dissected out, and the clamp was placed at the point of the epididymis and the specimen was removed.  The epididymis was repaired with #3-0 Vicryl stitch, and the tunica was closed appropriately.

Then, attention was given to the varicocele.  The spermatic cord was dissected out.  The cremasteric was opened.  The veins were identified and ligated with #3-0 silk suture.  After this was completed, attention was given to the vas.  The segment of the vas near the area of the varicocele ligation was dissected out using the sharp tip hemostat.  Once this was done, we then transected the vas to make sure there were no vessels included and then we took out a segment.

Hemostats were used and the proximal and distal segments were then tied appropriately with #3-0 silk x2 and the tips were fulgurated.  The patient's wound was closed with #3-0 chromic, and the skin was approximated with a running #4-0 Vicryl stitch.  The patient tolerated the procedure well.