Modified Radical Hysterectomy Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Complex pelvic/uterine mass.

POSTOPERATIVE DIAGNOSIS:
Uterine leiomyosarcoma with direct invasion into right pelvic sidewall.

OPERATION PERFORMED:
1.  Modified radical hysterectomy.
2.  Right ureterolysis.
3.  Right pelvic lymphadenectomy and biopsies.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

ANESTHESIOLOGIST:  Jean Doe, MD

ESTIMATED BLOOD LOSS:  1500 mL.

REPLACEMENT:  2 units of packed red blood cells and 2 units of fresh frozen plasma.

DRAINS:  Foley to GU bag and pelvic Blake drain.

OPERATION IN DETAIL:  The patient was taken to the operating room, placed in supine position, and given satisfactory general endotracheal anesthesia.  The legs were placed in the Allen stirrups.  The abdomen, perineum, and vagina were prepped with Betadine and draped in the usual sterile fashion and a Foley catheter was inserted sterilely.

Vertical incision was made from the symphysis pubis to above the umbilicus, subcutaneous tissue divided sharply to the fascia, the fascia was split in the midline, and the rectus muscles were separated.  The peritoneum was entered.  Washings were taken from the pelvis and the right upper quadrant.  A very large uterine mass was sharply and bluntly dissected away from the small bowel mesentery.  A couple of large packs were placed and the upper abdomen did display small bowel.  Hand-held retractors were used for exposure.

At this point, ascites was aspirated.  The right retroperitoneum was opened lateral to the infundibulopelvic ligament.  Adhesions were taken down between distal small bowel mesentery and the pelvic sidewall.  Bowel was then repacked.  The ureter and major vessels were identified.  The infundibulopelvic ligament was double ligated with locking Hem-o-lok clips and a Kelly clamp was placed on the back side.  This pedicle was cut.  The round ligament on the right was suture ligated and divided, held on a hemostat, and the anterior cul-de-sac peritoneum was then taken down with Bovie cautery.

In a similar fashion, the left retroperitoneum was opened with Bovie cautery.  The ureter and major vessels were identified.  The IP ligament was grasped with a Babcock clamp.  The IP ligament was then double ligated with locking Hem-o-lok clips.  The left round ligament was suture ligated and divided, and the anterior cul-de-sac peritoneum was then opened again with Bovie cautery, exposing the lower uterine segment.  The uterine vessels on the left side were then clamped with a curved Zeppelin clamp.

At this point, the Bookwalter retractor was placed.  The bowel was then further packed up with moistened laps.  Attachments from the uterine mass to the presacral peritoneum were then taken down with Metzenbaum scissors.  The ureter was lysed off the medial peritoneal leaf and retracted medially.  The pelvic sidewall peritoneum was then cut with Metzenbaum scissors.  The uterine mass was then elevated out of the cul-de-sac.  The patient had brisk bleeding from vessels in the parametrium at the uterosacral ligament.  This was managed with pickups, hemoclips, and Kelly clamp.  The supravesical artery was dissected out on the right side.  The takeoff of the uterine artery was hemoclipped for further hemostasis.  The curved Zeppelin clamp was then brought across the uterine vessels at the lower uterine segment.

At this point, the uterine fundus was then cut away with a scalpel and a single-tooth tenaculum was placed on the cervix.  A specimen was sent to the pathologist for further inspection which confirmed high-grade uterine leiomyosarcoma.  Multiple bleeding points in the retroperitoneum were then controlled with pickups and hemoclips.  The cardinal ligaments on each side were clamped with straight Zeppelin clamps.   A thin malleable blade was then used to retract the bladder.  The cardinal ligaments were cut and Heaney ligated with 2-0 Vicryl.  Right-angle Zeppelin clamps were brought across the uterosacral ligaments at vaginal corners and the cervix cut away.  The vaginal corners were suture ligated with 2-0 Vicryl.  The vagina was irrigated and closed with figure-of-eight 2-0 Vicryl suture.  Hemostasis was achieved on the peritoneum with multiple hemoclips and Bovie cautery.  The pelvis was thoroughly irrigated.

Lymph nodes were then removed from the common iliac artery and vein, and the external iliac artery and vein on the right side with pickups, Metzenbaum scissors, and hemoclips.  Avitene floss was then placed in the retroperitoneal spaces on each side.  A 15 Blake drain was placed in the posterior cul-de-sac, brought through the left lower quadrant, and sutured using #2-0 silk suture.  Upper abdominal packs were then removed.  Biopsies were obtained from the undersurface of the small bowel mesentery where the mesentery had been adherent to the uterine fundus.  The upper abdomen was thoroughly irrigated with warm sterile water, removing bloody ascites from the diaphragm on each side.  Seprafilm was then placed along the right and left pelvic sidewall, the anterior and posterior cul-de-sac.

All laps and retractors were removed.  Sponge and needle counts were correct.  Seprafilm was placed across the anterior abdominal wall.  The peritoneum and fascia were closed with running #2 Prolene, beginning at each end of the incision, proceeding toward the midline, and tying together and inverting the knots.  Subcutaneous tissues were irrigated, bleeding points were cauterized, the skin closed with clips, and the wound was covered with sterile dry bandage. The patient tolerated the procedure without difficulty, was extubated, and taken to recovery in stable condition.

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Abdominal Myomectomy and Seprafilm Placement Operative Sample

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, where general anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion in the dorsal lithotomy position, in stirrups. A speculum was placed in the vagina and the anterior lip of the cervix was grasped with an Allis clamp. The acorn retractor was introduced into the uterus and attached to the single-toothed tenaculum. The speculum was removed. Gloves were changed.  Attention was then turned to the patient's abdomen, where a Pfannenstiel incision was made on the skin using the scalpel and carried down to the underlying fascia using the Bovie. The fascia was incised and the incision extended laterally using the Mayo scissors and the Bovie. The fascia was grasped with two Kocher clamps and tented off the rectus muscles and dissected off with a combination of blunt and sharp dissection using the Bovie and Mayo scissors, both superiorly and inferiorly. Rectus muscles were separated bluntly. Peritoneal cavity was entered bluntly and the incision extended using Metzenbaum scissors. The uterus was palpated and noted to be large, approximately 18 weeks' size and irregular, with large fibroids. The Kirschner retractor was put into place, first at the sidewall retractors, then the bladder retractor, and then the upper abdominal retractor. The uterus was then able to be exteriorized from the abdomen initially, and, therefore, attention was turned to the large anterior uterine fibroid. Vasopressin was injected into the overlying serosa on the uterus to help it obtain hemostasis on the anterior fibroid along the line of the planned incision. The needle Bovie cautery was then used to incise the serosa and expose the fibroid. The fibroid was grasped with a towel clamp and shelled out using a combination of blunt dissection and Bovie cautery. The fibroid was removed. The base of the fibroid was then closed with a series of figure-of-eight sutures, then running suture, and then a third layer of running suture using 2-0 Vicryl in the fist layer, 2-0 chromic in the second layer, and 3-0 Vicryl in the third layer.  Attention was then turned to the posterior aspect of the uterus, where the posterior fibroid was injected with vasopressin and then incised using the Bovie cautery, grasped with towel clamp, and shelled out using blunt dissection and Bovie cautery. The base of the incision was closed with several figure-of-eight sutures using 2-0 Vicryl, then a running 2-0 Vicryl suture, and then a running 3-0 Vicryl suture. Several small fibroids had been removed from the inside portion of this incision on the posterior portion of the uterus. The uterus was easily exteriorized after removal of the anterior and posterior fibroids. Several other smaller fibroids were removed from the surface of the uterus with the surface being closed with 3-0 Vicryl. Attention was then turned to the fundus where vasopressin was injected along the serosa of the fundus, over the fibroids, and then an incision was made using the Bovie cautery along the two fibroids on the fundus of the uterus. They were shelled out using blunt dissection and Bovie cautery as well. All small fibroids within the incision were removed. The incision was closed first with several figure-of-eight sutures using 2-0 Vicryl, then a running 2-0 Vicryl, and then a 3-0 Vicryl. The uterus was inspected for any other fibroids. None were noted.  Fallopian tubes were then visualized and measured, given the patient's possible desire for tubal reanastomosis. The uterus was returned to the abdominal cavity, which was copiously irrigated, and the uterine incisions were inspected once again; no bleeding was noted. The Seprafilm was then placed across the posterior incision, the anterior incision, and the fundal incision in the uterus, and then placed over the bowel to prevent adhesions of the bowel to the uterus and the bowel to the anterior abdominal wall. The retractor was removed. All other instruments were removed from the abdomen. The rectus muscles were inspected. No bleeding was noted. The fascia was closed in a running fashion. The subcutaneous layer was copiously irrigated.  All bleeders were cauterized. Subcutaneous layer was closed in a running fashion and the skin was closed with staples. All sponge, lap, and needle counts were correct x2. The patient tolerated the procedure well.