Roux-en-Y Jejunojejunostomy, Hepaticojejunostomy Medical Transcription Sample

PREOPERATIVE DIAGNOSIS:  Liver cancer.

POSTOPERATIVE DIAGNOSIS:  Liver cancer.

OPERATIONS PERFORMED:

1.  Right trisegmentectomy.

2.  Roux-en-Y jejunojejunostomy.

3.  Roux-en-Y hepaticojejunostomy.

4.  Extensive lysis of adhesions.

5.  Repair of umbilical hernia, nonincarcerated, primary repair.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal tube anesthesia.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  150 mL.

DRAINS:  One JP drain to bulb suction.

SPECIMENS OBTAINED:

1.  Distal bile duct.

2.  Distal cystic duct.

3.  Right trisegmentectomy.

INTRAOPERATIVE FROZEN MARGINS:

1.  Cystic duct negative for malignancy.

2.  Bile duct negative for malignancy.

3.  Cut surface of the liver negative for malignancy.

4.  Primary tumor consistent with cholangiocarcinoma or hepatocellular carcinoma.

DESCRIPTION OF OPERATION:  The patient was placed supine on the operating table. After adequate IV access and IV sedation, the patient was intubated and anesthetized. Central venous cannulation and arterial cannulation were performed by Anesthesiology. A Foley catheter was placed by the nursing staff. The abdomen was prepped with Betadine solution, including the chest, and draped with sterile linen and sterile drapes. A right subcostal incision was created and taken down through the peritoneum with electrocautery. One hand was placed intraperitoneally and the surfaces were palpated. The peritoneum had no evidence of carcinomatosis. There were no other masses below the liver or within the mesentery. The mass within the liver was palpable. With no evidence of disease outside the liver between the CAT scan as well as palpation and exploration, the incision was carried to a bi-subcostal incision with midline extension. The falciform ligament was taken down between 0 silk ties. The next 50 minutes were then used to carefully take down adhesions between the small bowel, the omentum, the colon and the liver. The bowel structures and omentum were adherent to the gallbladder, which was invaded by cancer and the surface edge of the liver all the way down to the right triangular ligament. Many of these adhesions were taken down between 2-0 silk ligatures for hemostasis.

With the liver now freed up, the membranous portion of the falciform ligament was taken down with electrocautery to the hepatic veins. The porta hepatis was now explored. The right, middle, and left hepatic arteries were circumferentially dissected and vessel loops were placed. The portal vein was skeletonized and carried up to the bifurcation. The left portal vein was identified and a vessel loop was placed for control. The common bile duct was circumferentially dissected and was transected near the head of the pancreas. The distal margin of the bile duct was sent for frozen pathology. The cystic duct took off from the bile duct very low, just above where the common bile duct was transected. This was transected and also sent for distal margins and both came back negative.

The right lobe of the liver was now mobilized, taking down the triangular ligament and its attachments to the retroperitoneum. The peritoneum over the vena cava was taken down with blunt dissection and electrocautery. Four tributaries directly from the liver into the vena cava were taken down between ligatures and divided. Each one was oversewn at the vena cava with a 3-0 silk pop-off suture. The right lobe had two hepatic veins. Each one was circumferentially dissected and an umbilical tape was placed for control. Each one was then occluded and divided with endoreticulating vascular stapler. The right hepatic artery was divided between silk ties. The portal vein was divided right at the bifurcation and the proximal portion ligated as well as suture ligated with 3-0 silk ligatures. The right portal vein had been previously embolized.

The bile duct was palpated and its landmarks were identified. The hilum of the liver was now elevated and the bile duct to the right lobe was identified and circumferentially dissected, ligated, and divided. With all vascular structures and the biliary system now disconnected from the right lobe of the liver, the palpable tumor was identified and its margins were located. The margin between segment IV and the left lobe was found to be approximately 2 cm from the palpable mass. The Habib RFA dissector was now used to precoagulate the surface the liver from the right hepatic vein all the way to the porta hepatis, staying well away from the porta hepatis so as not to transmit heat to the biliary and vascular structures. After precoagulation, the liver tissue was then cut with scissors, transecting down to the major vascular structures. After the major vascular structures were divided, endoreticulating vascular staplers were used to occlude and divide the biliary and vascular structures in the remaining hepatic substance. The specimen was removed and sent to pathology for frozen evaluation. All frozen slides came back negative for malignancy. The cut surface of the liver was Argon beam coagulated at the areas that had any amounts of bleeding. Most were all dry. Around the bile duct, going to the left lobe, as well as the left hepatic artery, there was a small amount of oozing blood. FloSeal hemostatic gelatin matrix was then placed with Nu-Knit for persistent hemostasis.

Evaluation of the bile duct found that it was cut just below the takeoff between the anterior and posterior portions. A small tributary had been cut away from the anterior portion 2 cm away from the main orifice. This was oversewn with a 5-0 Maxon suture in interrupted style. The vena cava was evaluated and found with all ties to be intact. The retroperitoneum was Argon beam coagulated for hemostasis. The retracting system was now rearranged. The small bowel was followed from the ligament of Treitz to the ileocecal valve and no pathology was identified. Fifty centimeters from the ligament of Treitz, the bowel was brought in a retrocolic fashion anterior to the pylorus up into the hilum of the liver. This provided enough length for hepaticojejunostomy. The bowel was now brought down below the colon and divided with a 3.5 mm endoreticulating stapler. The mesentery was taken down past the second arcade branch. The branches were ligated and divided. The proximal portion of the Roux was now anastomosed in a side-to-side fashion to the distal jejunum in a two-layer fashion with 3-0 silk Lembert sutures and 3-0 Maxon running suture, full thickness. The distal divided jejunum was now brought up retrocolic through the previous tunnel and placed up in the hilum. An enterotomy was created 1 cm from the staple line in an antimesenteric fashion. The left bile duct was now anastomosed to the jejunum in a mucosa-mucosa technique with 5-0 Maxon interrupted full thickness sutures. The rent in the mesentery of the colon was tacked to the bowel to prevent herniation and to close the defect with individual 3-0 silk simple sutures. The rent in the mesentery below the colon for the jejunojejunostomy was closed with 3-0 interrupted silks as well. The abdomen was irrigated with sterile saline and antibiotic solution and aspirated dry. The cut surface of the liver was completely dry.

A 12 French flat JP drain was brought through a separate stab incision and placed within the resection bed. The hepaticojejunostomy and the repaired bile duct were covered with CoSeal fibrin glue. The abdomen was closed in a one-layer fashion with #1 PDS suture. The midline extension was closed in interrupted fashion with figure-of-eight and the bi-subcostal incisions were closed with running looped PDS. An On-Q pain pump was now placed with two limbs superior and subperitoneal to the wound. The catheters had been placed prior to closure. Each catheter was then prefilled with 0.5% Marcaine without epinephrine. The skin was reapproximated with sterile staples. The drain was attached to the skin with a drain stitch of 2-0 silk. The patient tolerated the procedure well and was hemodynamically stable throughout the case. He was taken to the recovery room in awake and stable condition.

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Rectus Recession Ophthalmology Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Thyroid eye disease with severe esotropia and left hypertropia; limitation of elevation and abduction, both eyes.

POSTOPERATIVE DIAGNOSIS:  Thyroid eye disease with severe esotropia and left hypertropia; limitation of elevation and abduction, both eyes.

OPERATION PERFORMED:  Bilateral medial rectus recession, right inferior rectus recession, isolation, and attempted recession of the left inferior rectus.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  This patient has a history of severe thyroid eye disease and has minus 6 limitation of abduction of the right eye with minus 4 limitation of elevation of the right eye. On the left eye, the left eye is frozen in adduction and depression with only the superior limbus visible above the lower lid margin. Eye muscle surgery was undertaken to improve alignment, promote binocularity, as well as to alleviate diplopia.

DESCRIPTION OF OPERATION:  Attention was first directed to the right eye after it was prepped and draped in the usual sterile ophthalmic fashion. Forced duction revealed that there was marked limitation of abduction and elevation of the eye to passive ductions. A radial fornix incision was made inferotemporally, along the lateral border of the inferior rectus muscle. The muscle was then isolated with a small and then large muscle hook, and forced duction of the muscle on the hook revealed that it was markedly tight. The conjunctival peritomy was then carried along the inferior limbus and winged, inferonasally. The inferior rectus muscle was then carefully dissected posteriorly, and the lower lid retractors were removed from the inferior part of the muscle belly. The muscle was then secured with a double-armed 6-0 white Dacron suture, which was difficult to place because of the marked restriction of the inferior rectus. The muscle was then very carefully disinserted from the globe, with great care taken not to imbricate sclera. After the muscle was off, there was still some resistance to passive elevation of the eye.

Attention was then directed to the medial rectus muscle, which was isolated with small and then large muscle hooks. The conjunctiva was then winged along the nasal limbus superiorly. The muscle was isolated with small and then large muscle hooks, and passive forced ductions revealed marked restriction of that muscle as well. The muscle was difficult to isolate because it was so tight. A double-armed 6-0 Dacron was once again used to isolate and secure the muscle. The muscle was then carefully disinserted from the globe with Aebli scissors with great difficulty because of the marked restriction. After the medial rectus muscle was off, it was somewhat easier to elevate the eye. The inferior rectus was then reattached 4 mm posterior to the old insertion with one-half tendon with nasal transposition. Once the inferior rectus was reattached to the globe, this caused an increase in resistance to passive abduction of the eye due the abducting action of the inferior rectus. The medial rectus was next sutured to the eye in a scleral fixation hang-back fashion giving a recession of 0.5 mm. The ends of the sutures were then trimmed, and the conjunctiva was then closed with simple interrupted 8-0 Vicryl sutures. The lids needed to be taped shut on the right side for attention to be directed to the left side, as there was greater amount of lagophthalmos.

Next, drapes were opened on the left side and a lid speculum was inserted. Even under anesthesia, the eye was still frozen in adduction and depression. It was not possible to get the inferonasal conjunctiva, so superior nasal incision had been made between the medial rectus and superior rectus. The conjunctival peritomy was then carried inferiorly and the medial rectus was isolated with some difficulty because of its extremely adducted position. A small hook was then exchanged for a large hook and the medial rectus was eventually isolated. Because the eye was frozen in adduction and depression, it was difficult to even place hooks. The muscle was then secured with a double-armed 6-0 Dacron suture, and with great difficulty, the muscle was disinserted from the globe. After the muscle was disinserted from the globe, attention was then directed to isolation of the inferior rectus on the left side. A variety of lid speculums were tried to get better exposure of the inferior rectus. The conjunctiva was then incised along the inferior limbus in order to try to gain better exposure. Even after cleaning the inferonasal quadrant, it was still not possible to visualize the inferior borders of the inferior rectus insertion.

Next, a Barbie retractor was used to pull down the nasal lid against the inferior orbital rim. With this and some great difficulty and pressing along the orbital rim with a small hook, it was sometimes possible to hook the nasal border of the inferior rectus. However, it was readily apparent that the inferior rectus was so tight that the inferior rectus inserted posterior to the equator of the globe. Thus, access could not be gained to the inferior rectus insertion. The case was discussed with Dr. Jane Doe and we elected to perform an orbitotomy at a later date to gain access to this very severely restricted inferior rectus due to thyroid eye disease. The medial rectus muscle was then recessed 7 mm on a hang-back suture and the conjunctiva was exposed carefully, as possible, given the severe amount of restriction of the globe. The conjunctiva was closed with simple interrupted 8-0 Vicryl sutures. TobraDex eye ointment was then instilled to the left eye. TobraDex ointment was instilled to the right eye after the half-inch Steri-Strips were removed from the lids, which had been holding it closed. The patient was awakened from anesthesia and taken to the recovery room in stable condition. There were no complications.

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Vascular Surgery Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSES:

1.  Severe segmental stenosis of the distal abdominal aorta.

2.  A 3.5 cm juxtarenal aneurysm between the left renal artery and the aortic stenosis.

3.  Right pelvic kidney.

4.  Chronic obstructive pulmonary disease.

POSTOPERATIVE DIAGNOSIS:  Not dictated.

OPERATION PERFORMED:  Aortobifemoral bypass graft using 19 x 8 Gelsoft Vascutek bifurcated graft.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  The patient presented with disabling claudication involving his lower extremities bilaterally. He was watched for close to two years. His symptoms had significantly deteriorated. The patient had absent bilateral femoral pulses. He underwent an MRA of the abdomen, which showed 90% stenosis of the distal aorta. The stenotic area was around 3 cm in length. Also, the patient had moderate left renal artery stenosis and right pelvic kidney. The right kidney has multiple branches feeding off of the stenotic aortic area. There is no main renal artery to the right kidney. He also was found to have a 3.5 cm aneurysm. The aneurysm extended from the stenotic area all the way to almost around a centimeter below the left renal artery. The patient was seen by Dr. Jeffrey Doe preoperatively for pulmonary and cardiac clearance. Extensive discussion with the patient was made on an outpatient basis. Different options were explained. He opted to proceed with aortobifemoral bypass graft with the intent to establish multiple things. One is to excise the abdominal aortic aneurysm that is located below the left renal artery. Also, the bypass will provide inflow to his lower extremities bilaterally and subsequently will relieve his ischemic lower extremity pain. At the same time, our intention was to allow the back flow through the stenotic aortic segment to perfuse the right kidney. The patient was agreeable to proceed with surgery and gave me his informed consent.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and was placed on the table in a supine comfortable position. A general endotracheal anesthesia was given to the patient without any problem. A Salem sump was introduced into the stomach to decompress his stomach. A Foley catheter was introduced into the bladder to monitor urine output. Knee-high Kendalls were placed to pump the legs during the operation. The abdomen, groins, and thighs were prepped and draped in the usual sterile fashion. The patient had received preoperative Ancef prophylactically. The procedure was started by making a longitudinal incision along the right groin. The incision was carried down to the skin and subcutaneous tissue. The common femoral artery was isolated. A vessel loop was placed around it. The superficial and deep femoral arteries were isolated. The vessel loops were placed around them.

Attention was then directed to the left groin. A longitudinal incision was made at that location. The incision was carried down through the skin and subcutaneous tissue. The left common, superficial, and deep femoral arteries were isolated. Vessel loops were placed around them. Attention was then directed to the abdomen. A longitudinal incision was made between the xiphoid and pubis. The incision was carried down through the skin and subcutaneous tissue. The fascia was opened in the midline. The abdominal cavity was entered. A minimal amount of adhesions were identified in the pelvis. These were freed and moved laterally. The liver felt normal. The spleen felt normal. The stomach and small bowel are normal in appearance. The colon was normal in appearance. No ascites was noted. Attention was then directed to the retroperitoneum. A Bookwalter retractor was placed. Retraction of the lateral wall of the abdominal cavity was performed. The dissection was carried down on the lateral aspect. The retroperitoneum was opened longitudinally. The incision was carried up from the iliac bifurcation all the way to the renal vein. The retroperitoneum was opened completely. The dissection was carried out along the inferior mesenteric artery, which was identified. The aneurysm was identified. The left renal artery was identified. The right kidney was visualized. It was located in the pelvis. There were maybe 3 or 4 less than 2 mm vessels feeding the right kidney. The inflow originates from a stenotic long segment atretic aorta. The iliac arteries felt to be calcified, but they were patent.

The patient was given 5000 units of heparin. Heparin was allowed to circulate for 3 minutes. A clamp was placed on the aorta just above the stenotic segment. A clamp was placed on the aorta below the left renal artery. The intention was to close the stenotic aortic area, allow the flow from this aortic segment just below the renal artery via the graft into the femoral arteries bilaterally. Flow retrograde through the external iliac will feed the kidney and the hypogastric system. The aorta will be suture ligated superiorly to allow backbleeding to the right kidney. There were multiple small vessels originating from the aorta. The aortic wall was very diseased. There was not enough room to use a Carrel patch to implant to the graft.

The aorta was clamped just immediately below the left renal artery and above the right renal origin. Perfusion to the right kidney was retrograde via the femoral system. The aneurysm was opened. Hemostasis was performed by ligating bleeding lumbar vessels. An 18 x 9 bifurcated Vascutek graft was spatulated. It was sutured superiorly with 3-0 Prolene on an SH needle. The proximal anastomosis was intact. Once this was established, the aorta just above the stenotic area and above the origin of the right renal arteries was suture ligated with Prolene sutures. As I said before, the aortic wall was very atrophic. There were no healthy viable tissues to implant a Carrel patch that includes all these little branches into the graft. The vessels were very small and it was almost impossible to implant them separately.

Tunnels were created between the groins and the retroperitoneal area. The grafts were tunneled all the way down to the groin. Attention was then directed to the left femoral system. The left common femoral artery was clamped. The left superficial and deep femoral arteries were clamped. Longitudinal arteriotomy was performed. The graft was spatulated. It was sutured into the left femoral artery. All vessels were allowed to backbleed. We had good backbleeding from the iliac circulation. The flow was restored to the lower extremities via an open limb of the graft. The other limb was tunneled to the right groin. The femoral artery was patent. The superficial and deep femoral arteries were clamped. The proximal common femoral artery was clamped. Longitudinal arteriotomy was performed. The graft was spatulated and was sutured into the femoral artery with 3-0 Prolene on an SH needle. Hemostasis was performed. Flow was restored to both lower extremities. The patient was stable. Blood loss was noted from flushing the aortic graft, from ligating the limbs of the graft, from flushing femoral vessels; it was estimated to be around 1200 mL. The feet were examined. They were warm and had dorsalis pedis pulses bilaterally.

Attention was then directed to the abdominal cavity. The retroperitoneum was examined. No bleeding was noted. The retroperitoneum was closed to cover the graft and separate it from the duodenum. Hemostasis was performed well. The fascia was closed with running looped PDS. Two sutures were used, one from above and one from below. The subcutaneous tissue was closed with running 3-0 Vicryl. The skin was closed with staples. Attention was then directed to the femoral area. The subcutaneous tissues were closed in the usual fashion, 3-0 Vicryl in two layers for the subcutaneous and staples for the skin. Hemostasis was intact. The patient had good palpable femoral and dorsalis pedis pulses bilaterally. The patient tolerated the procedure well.

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Repeat Low Transverse Cesarean Section Sample Report

PREOPERATIVE DIAGNOSES:

1.  Intrauterine pregnancy, 36 and 6/7 weeks.

2.  History of low transverse cesarean section x2.

3.  Early labor.

4.  History of breast cancer status post bilateral mastectomy.

POSTOPERATIVE DIAGNOSES:

1.  Intrauterine pregnancy, 36 and 6/7 weeks.

2.  History of low transverse cesarean section x2.

3.  Early labor.

4.  History of breast cancer status post bilateral mastectomy.

5.  Abdominal and pelvic adhesions.

OPERATION PERFORMED:  Repeat low transverse cesarean section via Pfannenstiel incision and lysis of adhesions.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Spinal.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  800 mL.

IV FLUIDS:  2200 mL.

URINE OUTPUT:  250 mL of yellow urine.

OPERATIVE FINDINGS:  Dense abdominal wall adhesions were noted with the rectus muscles densely adhesed to the overlying fascia. The rectus muscles were adhesed in the midline. The bilateral tubes and ovaries were normal and the uterus was normal other than dense adhesions of the bladder to the lower uterine segment. A viable male infant was delivered with clear amniotic fluid. The weight was 7 pounds 8 ounces and Apgars were 8 and 9.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old G3, P2-0-0-2 at 36 and 6/7 weeks who presented to the office with complaints of regular painful contractions about every 5 to 7 minutes. The patient's history is significant for previous lower transverse cesarean sections at 37 weeks for spontaneous labor. At the office visit, the patient was noted to be 1 cm dilated with blood-tinged discharge and the diagnosis of early labor was made. Risks, benefits and alternatives of repeat cesarean section at this gestation versus continued expectant management were discussed with the patient. The risks of delivery and complications of prematurity were discussed. Consent was obtained. The patient was sent to the hospital. Fetal heart rate monitoring in the labor and delivery recovery room area was reassuring.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room where spinal anesthesia was placed and found to be adequate. The patient was placed in the dorsal supine position with a leftward tilt. A Foley catheter was placed and the abdomen was prepped in the usual sterile fashion and draped. A Pfannenstiel incision was then made approximately 2 cm above the pubic symphysis and overlying the previous Pfannenstiel incisions. The incision was carried down to the underlying fascia with a scalpel. The fascia was incised in the midline and extended laterally with a scalpel. The superior aspect of the incision was grasped with Kocher clamps and the underlying rectus muscles were carefully dissected off using sharp dissection. The same procedure was performed inferiorly. Due to the extensive adhesions in this area, small venous oozing areas were made hemostatic with Bovie cautery at this time. The rectus muscles were then separated high in the incision with the scalpel and the peritoneum was identified and elevated with hemostat. The peritoneum was entered with a scalpel. A finger was advanced through the peritoneal incision and the anterior abdominal wall was noted to be free of adhesions allowing the peritoneal incision to be extended superiorly and inferiorly. At the inferior aspect of the incision, the bladder was noted to be high onto the peritoneum. The bladder blade was inserted and the scarred bladder was visualized and the vesicouterine peritoneum was identified and entered sharply. An attempt to create the bladder reflection was made with oozing noted from the adhesions present on the bladder.

Once the bladder was felt to be safely dissected off the lower uterine segment, the uterus was incised in the transverse fashion with a scalpel. The incision was extended with Mayo scissors. The infant's head was delivered atraumatically and the nose and mouth were bulb suctioned. The infant was delivered and placed onto the surgical field where the cord was clamped and cut. The infant was handed off to the awaiting nursery personnel. Cord bloods were obtained. The placenta was manually removed intact. The uterine fundus was noted to be free of adhesions and was delivered through the abdominal incision. The bladder blade was reinserted and the uterus was cleared of all clots and debris. The extent of the uterine incision was grasped with Pennington clamps and 0 chromic suture was used to reapproximate the incision in a running locked fashion. A second layer of the same suture was then used to imbricate the first layer. With the placement of the second layer of sutures, hematoma developed in the right aspect of the uterine incision extending down into the broad ligament. An O'Leary suture was placed superior to the uterine incision with continued expansion of the hematoma. A second O'Leary stitch was then placed inferior to the incision with excellent control of the bleeding in this area. Diffuse oozing was noted from the lower aspect of the uterine incision related to the previous bladder adhesions and these were made hemostatic either with Bovie cautery or multiple figure-of-eight sutures of 0 chromic.

Attention was then turned to the bladder and extensive diffuse oozing was noted from the anterior of this reflection. Attempts at Bovie cautery were unsuccessful and interrupted 3-0 Vicryl sutures were placed in the area to finally obtain hemostasis. Given the extent of adhesions, the decision was made to retrograde fill the bladder with sterile milk to confirm the integrity of the bladder, and this was done successfully with no leaks of milk noted into the surgical field. Once hemostasis was assured, the uterus was returned to the patient's abdomen and the pelvis and abdomen were irrigated and the gutters were cleared of all clots and debris. Seprafilm was placed over the uterine incision and the bladder reflection brought up and placed over the Seprafilm.

The peritoneal edges were reapproximated using 2-0 Vicryl running stitch, and with the placement of the suture, continued red oozing was noted from the abdominal cavity, and the peritoneal incision was opened again and the uterus was reinspected and hemostasis confirmed. The bladder was again reinspected and hemostasis was confirmed. The peritoneal incision was again closed using a 2-0 Vicryl running stitch. The rectus muscles were inspected again and the right rectus muscle was noted to have significant amount of bleeding from one perforator, which required placement of figure-of-eight 3-0 Vicryl suture x2. Once hemostasis was assured, the fascia was reapproximated using 0 PDS suture in a running fashion to the midline. The subcutaneous layer was irrigated and made hemostatic with Bovie cautery. Interrupted 3-0 Vicryl sutures were placed in the subcutaneous. Given the extent of the surgical time, the spinal anesthesia was beginning to wear off and the patient was experiencing mild pressure and discomfort with the surgery at this point and 15 mL of 0.5% Marcaine with epinephrine were then injected into the incision and the skin was closed with staples. All sponge, lap, and needle counts were correct x3. The patient remained in good condition throughout the procedure and was taken to the recovery room. The male infant was taken to the nursery prior to conclusion of the cesarean section in good condition.

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Neonatal / Infant Discharge Summary Sample          Delivery Note Transcribed Sample Report

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Laparoscopic Nissen Fundoplication Medical Transcription Operative Sample

PREOPERATIVE DIAGNOSES:

1.  Chronic gastroesophageal reflux disease.

2.  Sliding axial hiatal hernia.

POSTOPERATIVE DIAGNOSES:

1.  Chronic gastroesophageal reflux disease.

2.  Sliding axial hiatal hernia.

OPERATION PERFORMED:  Laparoscopic Nissen fundoplication.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  30 mL.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  This patient presents with a history of gastroesophageal reflux disease, which has been poorly controlled with maximal medical management. Preoperative evaluation with upper GI series and upper endoscopy revealed a sliding axial hiatal hernia without evidence of Barrett's esophagus. The patient’s 24 hour pH study was positive for pathological acid reflux. The patient will now undergo planned laparoscopic Nissen fundoplication for chronic gastroesophageal reflux disease and sliding axial hiatal hernia.

DESCRIPTION OF OPERATION:  The patient was transported to the operating room and placed supine on the operating table. Following induction of satisfactory general endotracheal anesthesia, the patient was placed in the dorsal lithotomy position using Allen stirrups and appropriate padding of all pressure points. The abdomen was then prepped and draped in the customary fashion using Betadine solution and sterile towels and sheets. A skin incision was made approximately 8 cm inferior to the xiphoid process superior to the umbilicus and to the left of the midline. The dissection was carried down to the level of the anterior fascia and the abdominal cavity entered under direct vision using an Optiview trocar. Carbon dioxide gas was instilled and satisfactory pneumoperitoneum was achieved without evidence of respiratory compromise. The 30 degree laparoscope with video camera was threaded through this trocar site and the upper abdomen explored.

Examination of the right upper quadrant revealed no evidence of inflammatory changes in the region of the gallbladder fossa. The liver was grossly normal without nodularity over its surface and there was no evidence of splenomegaly. The anterior serosal surface of the distal fundus and antrum of the stomach were unremarkable. Having completed the exploration, a 10 mm trocar was placed along the left costal margin at the midclavicular line and a 5 mm trocar placed on the left costal margin at the anterior axillary line. Two additional 5 mm trocars were placed in the subxiphoid position as well as in the right upper quadrant lateral to the rectus musculature. The 5 mm liver retractor was introduced in the right upper quadrant trocar site and used to elevate the left lobe of the liver. This allowed for complete exposure of the esophageal hiatus. A sliding axial hiatal hernia was present and was easily reduced from the mediastinum.

The gastrohepatic ligament was opened over the caudad lobe of the liver using the Harmonic shears and the hepatic branch of the vagus nerve was identified and carefully preserved. The peritoneal incisions were extended over the left and right crus and the mediastinum entered. The esophagus was circumferentially mobilized and all vessels encountered controlled with the Harmonic shears. The anterior and posterior vagal nerve trunks were identified and the posterior nerve trunk left in place along the posterior wall of the esophagus. The posterior aspect of the gastroesophageal junction was fully mobilized as well, and a pediatric Penrose drain passed around the esophagus at this level. This was secured in place with a 0 PDS Endoloop. Using the drain for retraction, the esophageal mobilization was completed to allow for approximately 3-4 cm of the esophagus to lie comfortably within the abdominal cavity without tension.

Next, the lesser sac was entered along the greater curvature of the stomach inferior to the inferior pole of the spleen. The short gastric vessels were divided with the Harmonic shears to the level of the left crus and care was taken to ensure that the entire posterior aspect of the upper fundus of the stomach was completely mobilized. The diaphragmatic defect was then closed posteriorly using horizontal mattress sutures of 0 Ethibond and felt pledgets. The closure was sized to allow for passage of a #60 Maloney dilator through the esophageal hiatus. The dilator was withdrawn back into the thoracic esophagus and the posterior aspect of the upper fundus of the stomach was passed posteriorly to the esophagus. The esophagus appeared to lie comfortably within the bed of the fundus and there was no evidence of tension. The dilator was advanced back into the lumen of the stomach under direct vision and the fundoplication completed using interrupted 2-0 Ethibond sutures. The suture line was oriented at the 10 to 11 o'clock position and the superior and inferior sutures were anchored to the wall of the esophagus. The medial stitch was placed between the walls of the fundus of the stomach. The dilator was then withdrawn and the wrap secured to the diaphragm at the 10 o'clock and 2 o'clock positions using 2-0 Ethibond suture. At the completion of the fundoplication, it measured approximately 2 cm in length, appeared to have the proper geometry, and there was no evidence of tension.

The area of dissection was thoroughly irrigated with Kantrex solution and checked for hemostasis. Any remaining fluid was evacuated and the suction irrigator used to remove as much carbon dioxide gas as possible. The trocars were removed and the incisions irrigated with Kantrex solution. The fascia opening at the 10 mm trocar sites were closed with 0 Vicryl suture and 0.5% Marcaine instilled into the incisions. The skin was closed with 4-0 Vicryl subcuticular suture and Benzoin and Steri-Strips as well as Tegaderm dressing placed across the incisions. The patient was then awakened and transported back to the recovery room in satisfactory condition with sponge and needle counts reported as correct at the end of the procedure.

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Cochlear Implantation Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Bilateral sensorineural hearing loss.

POSTOPERATIVE DIAGNOSIS:  Bilateral sensorineural hearing loss.

PROCEDURES PERFORMED:

1.  Nucleus Freedom cochlear implant, left.

2.  Steroid perfusion.

3.  Operating microscope with facial nerve monitoring.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal, local 1% lidocaine with 1:100,000 epinephrine.

DRAINS:  None.

SPECIMENS:  None.

IV FLUIDS:  One liter of crystalloids.

URINE OUTPUT:  Not recorded.

ESTIMATED BLOOD LOSS:  Less than 75 mL.

ANTIBIOTICS:  One gram of IV cefazolin, topical Avelox irrigation.

STEROIDS:  Decadron 8 mg IV.

COMPLICATIONS:  None.

POSTOPERATIVE CONDITION:  Stable. The patient will be admitted to the PACU and then admitted for overnight observation.

INDICATIONS FOR OPERATION:  This patient was referred to me for bilateral sensorineural hearing loss. The patient had little benefit with her hearing aids due to the level of hearing loss. Options of continued hearing aid use versus surgery were discussed with the patient. The patient wanted to proceed with surgery. We discussed left versus right cochlear implantation. We discussed sequential implantation. Since the patient uses the hearing aid on the right and considers that to be her hearing ear, she wanted to have the left side implanted; although, the patient was told it is possible that she would actually benefit more from the right side. The patient has a questionable history of prior stroke. She was told that this may reduce her chance of good success with the cochlear implant. Despite this, both she and her husband wanted to proceed with the surgery. All the potential risks and complications were discussed including no guarantee of success, need for revision surgery, need for cochlear implant removal if there is infection, risk of meningitis, brain abscess, facial nerve paralysis, continued deafness, dizziness, tinnitus, taste changes, wound healing problems, cosmetic concerns, auricular numbness, as well as other significant problems or complications. Despite the potential risks and complications, the patient and her husband desired to proceed with the surgery.

INTRAOPERATIVE FINDINGS:

1.  Well-aerated mastoid.

2.  Slight difficulty inserting the active electrode of the cochlear implant due to the preexisting curvature of the active electrode noted upon removal from the implant package.

3. See procedure in detail section below for more details.

DESCRIPTION OF OPERATION:  The patient was taken from the preoperative holding area to the operating room where she was placed supine on the operating room table. The patient was intubated. Once the endotracheal tube was secured, the table was rotated 180 degrees. SCDs were placed on the patient's legs. She was adequately padded, belted, and test rolled to make sure she was in a good position on the table. Hair was shaved posterior and superior to the left auricle. The proposed incision site was marked with a marking pen and infiltrated with local. Facial nerve monitoring needle electrodes were assessed for proper placement and functioning.

After she was prepped and draped in standard surgical fashion, a 15 blade scalpel was used to make a hockey stick incision. It was carried from the postauricular sulcus region up into the scalp. Temporalis fascia was harvested. Weitlaner was used to retract the soft tissue. Microscope was brought into view in the surgical field. Palva flap was created with Bovie electrocautery. The Bovie was used until cochlear implant packages opened up, at which point the Bovie tip was removed and only bipolar cautery was used. Antibiotic irrigation was used throughout the procedure. Complete mastoidectomy was performed with cutting, coarse and fine diamond burs. Tegmen was identified. Sigmoid was identified. Lateral semicircular canal was identified. The incus was identified. Facial nerve was identified in the mastoid and tympanic segments and extended facial recess procedure was performed. This was done because of the narrow facial recess and inability to get to the round window without sacrificing the chorda tympani nerve.

After identifying the incudostapedial joint on the round window, the cochlear implant well was drilled over two fingerbreadths behind the EAC. This well was drilled larger than the size of the implant to help it be on a flatter surface of the bone. Suture holes were created and nylon suture was placed. The implant was placed and tied down to the stitch. The ground electrode was placed. There was difficulty in advancing the electrode due to preexisting curvature noted on the active electrode. However, the cochleostomy was large enough to finally advance the active electrode. There was full insertion. Stylet was then removed. Once stylet was kept in place and advanced, off-stylet technique was not used due to the preexisting curvature over the electrode. Solu-Medrol 100 mg/mL was then placed into the cochleostomy. Temporalis fascia was then used to close the cochleostomy site. Intraoperative photos were taken.

The wounds were irrigated with antibiotic irrigation. Interrupted Vicryl sutures that were antibacterial-coated were placed in subcutaneous tissue and the skin flaps and Prolene sutures were used to close the skin. All sponge, needle, and instrument counts were correct at the end of the case. The patient tolerated the procedure well, was extubated, and transferred to the recovery room in stable condition. The patient will be admitted for overnight observation.

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Robotic-Assisted Laparoscopic Radical Prostatectomy Transcribed Sample Report

PREOPERATIVE DIAGNOSIS:  Clinically localized prostate cancer.

POSTOPERATIVE DIAGNOSIS:  Clinically localized prostate cancer.

OPERATIONS PERFORMED:

1.  Robotic-assisted laparoscopic radical prostatectomy, difficult.

2.  Insertion of Foley catheter.

SURGEON:  John Doe, MD

ASSISTANTS:

1.  Jane Doe, MD

2.  Bradford Doe, MD

ANESTHESIA:  General anesthesia.

SPECIMENS REMOVED:  Radical prostatectomy specimen.

ESTIMATED BLOOD LOSS:  500 mL.

COMPLICATIONS:  None.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old gentleman who presented with an elevated PSA at a level of 7.1. He had a prostate needle biopsy performed, which revealed Gleason 3+3=6 adenocarcinoma of the prostate involving 20% of one of the specimens on the left base. The patient’s metastatic workup has been negative. All of the different management options have been discussed with the patient and he elected to proceed with robotic-assisted laparoscopic prostatectomy.

DESCRIPTION OF OPERATION:  The patient was given preoperative antibiotics as well as preoperative subcutaneous heparin. He was taken back to the operative suite and moved onto the table in the supine position. General anesthesia was induced. His position was then changed to the lithotomy position and all bony prominences and pressure points were appropriately padded. The abdominal and perineal regions were prepped and draped in the typical fashion. A Foley catheter was inserted into the bladder with return of clear urine. A midline supraumbilical incision was made with a #15 blade, approximately 2 cm in length. This was deepened sharply to the rectus fascia. Stay sutures were placed on either side of the rectus fascia. A Veress needle was inserted into the peritoneal cavity. The position of the needle was confirmed after injecting and aspirating saline. Pneumoperitoneum was created.

The Veress needle was then replaced with a 12 mm trocar. The camera was introduced through this trocar and the peritoneal cavity was inspected. There were some intraperitoneal adhesions that were visualized. These were mainly in the right upper quadrant at an area where the patient had had a previous open cholecystectomy. There were also some adhesions in the right lower quadrant where the patient had previous appendectomy. The left robotic trocar was inserted and laparoscopic scissors was then used through this trocar in order to take down the adhesions in the right upper quadrant. The fourth arm trocar was then inserted under direct vision followed by the right robotic trocar. We then placed a 12 mm trocar in the right upper quadrant under direct vision and a 5 mm trocar medial to this. All of these were inserted under direct laparoscopic vision. The da Vinci robot was then docked to the robotic trocars.

The procedure started by reflecting the bladder off the anterior abdominal wall. The space of Retzius was dissected. The prostate was identified and cleaned off. Starting on the patient's right side, the endopelvic fascia was carefully dissected and opened in order to dissect the space between the prostate and the levator ani muscle. This was repeated on the patient's left side. The dorsal vein was identified and a stitch was applied to the dorsal vein in order to tie it off. After the dorsal vein had been completely tied off, the dissection was returned to the region of the bladder neck. The anterior bladder neck was divided at the prostatovesical junction. The Foley catheter was identified within the bladder. The bladder neck dissection was continued posteriorly after the Foley was removed. The posterior bladder neck was divided carefully and the dissection was carried through the posterior layers of the bladder wall. The vas deferens and seminal vesicles were then identified on either side and carefully dissected free. Denonvilliers' fascia was then divided at the plane between the posterior surface of the prostate and the rectum could be developed. This was developed using a combination of blunt and sharp dissection. The left prostatic pedicle was then divided using a combination of blunt and sharp dissection and Hem-o-lok clips.

We then turned our attention to the right prostatic pedicle, which was taken down in a similar fashion. We then approached the apex of the prostate. The dorsal vein complex and the apex of the prostate were divided carefully and then the rectourethralis muscle was divided sharply. The prostate specimen was completely freed and placed in an Endocatch bag. The site was then examined for hemostasis, which was found to be adequate. The bladder neck was visualized and there was no need for further bladder neck reconstruction. The anastomosis between the urethra and the bladder neck was completed using two continuous 2-0 Monocryl sutures tied to each other. Each of the sutures was 16 cm in length. The anastomosis was secured intermittently with laparoscopic tie absorbable clips. A Foley catheter was placed without difficulty into the bladder after the anastomosis was completed. The bladder was distended with 120 mL of normal saline and there was no evidence of extravasation confirming a watertight anastomosis. Again, hemostasis was examined and found to be adequate. The JP drain was then inserted through the exit of the fourth robotic trocar site. The drain was secured to the skin with a silk suture.

The robot was then undocked from the patient. The patient was moved out of Trendelenburg position and the laparoscopic sites were closed under laparoscopic vision using a port closure device and 0 PDS interrupted suture. The midline incision was then extended in order to remove the large specimen. The midline incision was closed with interrupted 0 PDS sutures. The skin was closed with 4-0 Vicryl sutures followed by Dermabond. The specimen was sent for pathologic analysis. The patient was awakened from the procedure, extubated, and transferred to the postanesthesia care unit in stable condition.

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Laparoscopic Total Abdominal Colectomy with End Ileostomy and Repair of Bladder Injury Transcribed Medical Transcription Operative Sample Report

PREOPERATIVE DIAGNOSIS:  Medically refractory ulcerative colitis.

POSTOPERATIVE DIAGNOSIS:  Medically refractory ulcerative colitis.

OPERATIONS PERFORMED:
1.  Laparoscopic total abdominal colectomy with end ileostomy.
2.  Repair of bladder injury.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

IV FLUIDS:  3800 mL.

ESTIMATED BLOOD LOSS:  Less than 50 mL.

URINE OUTPUT:  650 mL.

POSTOPERATIVE CONDITION:  Stable.

INDICATIONS FOR SURGERY:  The patient is a (XX)-year-old female with medically refractory ulcerative colitis involving primarily the rectum and rectosigmoid. The patient has been unresponsive to steroids. I have had a long discussion with the patient in the office concerning optimal management. I recommended she undergo total abdominal colectomy with end ileostomy. I informed the patient that this could be potentially performed laparoscopically but that there was a high risk of converting to an open procedure. The patient understood and agreed to proceed.

DESCRIPTION OF OPERATION:  After obtaining informed consent, the patient was taken to the operating room and placed on the operating table in the supine position. Compression boots were applied. Perioperative IV antibiotics were given. Subcutaneous heparin was administered. The patient then underwent general endotracheal anesthesia. Bean bag was then desufflated. She was then prepped and draped in the usual sterile manner. Attention was first paid to her umbilicus where a supraumbilical incision was made with an 11 blade. Dissection down to the abdominal fascia was performed. A 12 mm trocar was then placed in the Hasson fashion. Gas insufflation was obtained.

The 10 mm, 30-degree laparoscope was then placed into the abdomen. The abdomen was then briefly explored and no abnormalities were seen. Four 5 mm trocars were then placed under direct vision, two in the left lower quadrant and two in the right lower quadrant. Dissection was begun at the cecum. The cecum was identified and retracted inferiorly and laterally. The ileocolic vessels were identified. These were then taken carefully with 5 mm LigaSure device. In the retroperitoneal plane, below the level of the colonic mesentery, the duodenum was identified. Dissection was carried out to the lateral pelvic sidewall and up towards the hepatic flexure. The proximal transverse colon was then identified. The greater omentum was removed from the proximal transverse colon. Dissection was then performed at the ileocecal junction up the right pelvic sidewall to meet with our medial dissection. The hepatic flexure was then mobilized carefully with a combination of Bovie electrocautery as well as a LigaSure device. We then began dissection more distally from our transverse colon. The gastrocolic ligament was then identified and divided with Bovie electrocautery separating the omentum from the transverse colon. This was continued toward the splenic flexure. We then retracted our transverse colon superiorly and anteriorly and then identified the middle colic vasculature as well as the mesentery in this area. This was then transected carefully with LigaSure device. We then continued our dissection through the gastrocolic ligament towards the splenic flexure.

Once the splenic flexure was reached, we then began our left colon dissection. We removed the rectosigmoid from the pelvis. We then retracted the rectosigmoid superiorly and identified the IMA pedicle beneath, of which we performed a dissection with Bovie electrocautery. We then gained access in the retroperitoneum underneath the IMA pedicle and then identified our left ureter. Dissection underneath this plane was then performed laterally and inferiorly to move the ureter out of the way. We then made a window distal to the IMA pedicle and then transected our IMA carefully with a 5 mm LigaSure device. We continued our dissection towards the splenic flexure between the colonic mesentery and the retroperitoneal structure staying above Gerota's fascia. We then carried this dissection laterally onto the left lateral pelvic sidewall. We then dissected up the left lateral pelvic sidewall up towards the splenic flexure with Bovie electrocautery freeing our colon segment from the retroperitoneal structures. The splenic flexure was then taken down carefully with a combination of Bovie electrocautery as well as a LigaSure device. We then reassessed where our dissection planes were. We had some colonic mesentery to primarily the splenic flexure and distal transverse colon to go. This was then taken down with the LigaSure device carefully.

Once our colon was freely mobilized, we then did the open portion of the procedure. We made a Pfannenstiel incision in a skin crease with a 10 blade. The subcutaneous tissue was then divided with Bovie electrocautery. Dissection down to the anterior fascia was then performed. This was done open in a curvilinear fashion. The dissection plane was then performed below the fascia and above the rectus muscle superiorly and then inferiorly. We then opened our muscle and peritoneum in the midline. Dissection was continued proximally throughout the length of our wound and then distally. There was a lot of fat distally and we then created a very small hole in the bladder. This was repaired with multiple interrupted 3-0 Vicryl sutures. We then placed a protractor drape. Our rectosigmoid was identified and the colon was then pulled out through the incision. The remaining mesentery to the rectosigmoid junction was then taken between Kocher clamps and tied with 0 Vicryl sutures. The colon was then transected just proximal to the rectosigmoid junction with a TX-60 stapling device. We then removed the remainder of the colon from the abdomen. The ileocecal junction was identified. The mesentery was completely taken at that point between Kocher clamps and 0 Vicryl sutures.

We passed a specimen off the field. It was opened and examined. There was no evidence of neoplasia, but it did have a significant amount of distal inflammatory change. We then made our ileostomy aperture. A small skin disc was removed with a cautery device. Dissection through subcutaneous tissue was performed down to the anterior fascial sheath. This was then opened and divided. The muscle was split and the posterior sheath was then opened. We then passed our terminal ileum up through the aperture. There was absolutely no tension. We then irrigated our wound. We then went back laparoscopically to ensure that our ileostomy had the correct orientation. It was twisted 180 degrees, which was then corrected.

We then closed the Pfannenstiel incision. The peritoneum was closed with a running 0 Vicryl suture. The muscle was closed with three interrupted figure-of-eight 0 Vicryl sutures. The fascia was closed with a running 0 Vicryl suture. The wound was irrigated copiously with saline. The subcutaneous tissue was closed with multiple interrupted 3-0 Vicryl sutures. The skin was then closed with a running 4-0 Monocryl. The abdomen was then desufflated. The trocars were then removed. The wounds were irrigated and closed. The umbilical wound was closed with 0 Vicryl suture that had been previously placed. The skin was then closed at each site with 4-0 Monocryl suture. Dermabond was then applied. The stoma was matured in a Brooke fashion with multiple interrupted 3-0 chromic sutures. The stoma appliance was applied. The patient was then awakened, extubated, and taken to the recovery room in good condition.

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Plastic Surgery Medical Transcription Transcribed Surgical Example Report

PREOPERATIVE DIAGNOSIS:  Acquired defect, bilateral breasts, status post bilateral mastectomies with attempted reconstruction.

POSTOPERATIVE DIAGNOSIS:  Acquired defect, bilateral breasts, status post bilateral mastectomies with attempted reconstruction.

OPERATION PERFORMED:  Bilateral free TRAMs.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

DRAINS:  Seven, two to each breast and three to the abdomen.

SPECIMENS REMOVED:  Right implant and left tissue expander, but no tissue.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  The patient was seen in the preoperative holding area and her abdomen and chest were marked with midline lines as well as inframammary folds. Also, marked the expected flap tissue. The patient was then taken back to the operating room and placed on the table in the supine position. Anesthesia was induced without difficulty. At this point, we made incisions, first to the right side. We dissected down and removed the implant, which had been in good position on the right side. We dissected down overlying the right third rib and third costal cartilage. Once we were through the perichondrium, we elevated around the third costal cartilage and used a rongeur to remove the third costal cartilage all the way to basically the lateral sternal border. Once the rib was out of the way, the perichondrium was elevated carefully and was removed, revealing the right internal mammary artery and vein. These were dissected out as well as some of the intercostal musculature was dissected out to free up a good length of the internal mammary vessels to do our anastomosis. Once we were happy with this side, the same process was performed on the left side. The left tissue expander which was sitting way too far, medially, was removed. It was intact. Then, the third costal cartilage was identified and it was removed. The internal mammary vessels were dissected out in a similar manner. Moist gauze was placed into each breast defect and then attention was turned to the abdomen.

We started by dissecting the superior margin of the flap just superior to the umbilicus down to the level of the fascia and then dissected out the inferior margin of the flap. We identified the superficial inferior epigastric artery and vein bilaterally and these were clipped off as they were too small to support the flap bilaterally. We then raised the flap from the right side first, left side second. We raised the flaps up laterally and identified several perforators in the superior portion of the right flap and subsequently similar mirroring perforators were identified on the superior portion of the left flap. The flaps were divided down the middle after the umbilicus had been dissected out. Once we were happy that we had identified a healthy group of perforators, we incised into the fascia of the rectus abdominis through the anterior rectus fascia and identified the deep inferior epigastric artery and veins. These were dissected down to the level of the internal iliacs and then dissected out following them until they reached the perforators, dividing all branches with hemoclips until reaching the level of the perforators that were being kept for the flap.

Once this was done, we split the muscle, divided the muscle surrounding those perforators and then again repeated similar process on the left side, freeing up the vessels all the way up to the level of the perforators, splitting the muscle and the fascia, surrounding all the perforators and sparing a medial and lateral strip of muscle bilaterally. Once we were happy with our flap dissection, we allowed the flaps to sit on the belly for about 20 minutes, making sure that they still appeared to be healthy. They did both continue to bleed so at that point the left flap was divided and transferred up to the right chest.

At this point, using the operative surgical microscope, we cleaned up the ends of the flap vessels, the inferior epigastric vessels, and also dissected free the remainder of the vessels. We placed our clamps proximally on the internal mammaries and then ligated the vessels distally. The ends of the internal mammaries were cleaned up under the microscope. Once we were happy with that and we were happy with the inflow from the internal mammaries, we did the venous anastomosis using 9-0 nylon sutures in interrupted fashion. Then, we did our arterial anastomosis. These went smoothly; however, after a few seconds being off ischemic time, the flap did not appear to be getting good arterial flow so we revised the arterial anastomosis and were then happy with the flow. We then went to the contralateral side and were preparing the left chest to receive and just about to go ischemic with the right flap, when we looked at the right breast and again were unhappy with the arterial inflow and so this time we took the entire arterial anastomosis down and performed it again. At this point, we had even more vigorous flow than before so we were happy with it at this point.

Now, we finally turned our attention to the left breast where we ligated the deep inferior epigastric vessels and brought the right abdominal tissue to the left breast. Under the microscope again, the distal internal mammaries were ligated and once we were happy with the internal mammary inflow, the vessels were cleaned up under the operative microscope. The venous anastomosis was performed first and then the arterial anastomosis, again using 9-0 nylon and simple interrupted sutures. When we came off of ischemic time again, we were not happy with the arterial flow into the left side so we again went ischemic, flushed the flap and performed a new arterial anastomosis. This time, when we came off ischemic time, the flap flow was excellent. At this point, we checked for hemostasis bilaterally as well as in the abdomen. The bilateral flaps were inset using 3-0 Vicryl. The right flap, because it had been only partially expanded and did not have as much need of breast skin as an envelope, had a small area approximately 4 x 2 cm in dimension that could not be closed. We applied bacitracin and Adaptic to this. Both flaps remained pink with good capillary refill throughout the remainder of the case. We found Doppler signals and placed marks at each of those sites.

We then turned our attention to the abdomen, which was elevated all the way up to the level of the xiphoid and subcostal margin. The patient was placed in lawn chair position and the three drains were placed as well as a pain pump to aid with postoperative pain control. The umbilicus site was marked on the anterior abdominal wall and the umbilicus was brought through an incision made through the abdominal flap.

At this point, the abdomen was closed in three layers using 2-0 Vicryl for the Scarpa's layer, 3-0 Vicryl deep dermal sutures and then a running stitch using 4-0 Monocryl. The drains were all sutured in with 4-0 nylon. We sutured the umbilicus into position using 5-0 nylon. These were half buried mattress sutures. The abdominal incision was dressed with benzoin and Steri-Strips. The umbilicus was dressed with bacitracin and Adaptic and the breasts were dressed with bacitracin and Adaptic. The patient was kept in a flexed position and a postsurgical bra with fluffs was applied loosely and the area was cut out to prevent pressure. Again, Doppler signals were checked and were present. The patient tolerated the procedure well and was transferred to the PACU in stable condition. The patient was extubated prior to transfer.

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General Surgery Medical Transcription Transcribed Operative Sample Report

PREOPERATIVE DIAGNOSIS: Rectal cancer.

POSTOPERATIVE DIAGNOSES:
1. Rectal cancer.
2. Umbilical hernia.

OPERATIONS PERFORMED:
1. Laparoscopic low anterior resection.
2. Laparoscopic mobilization of splenic flexure.
3. Umbilical hernia repair.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

OPERATIVE FINDINGS:
1. Rectal cancer.
2. Umbilical hernia.
3. Obesity.

SPECIMENS: Sigmoid colon and rectum, proximal and distal margins.

ESTIMATED BLOOD LOSS: 250 mL.

IV FLUIDS: 4000 mL.

ANTIBIOTICS: Ancef and Flagyl.

DRAINS: None.

COMPLICATIONS: None.

POSTOPERATIVE CONDITION: Stable.

INDICATIONS FOR SURGERY: The patient is a very pleasant (XX)-year-old male referred to me for rectal cancer. Recently, the patient developed bright red blood per rectum on the toilet paper and in the stools over the last few months. He underwent colonoscopy, which demonstrated rectal cancer. Biopsies demonstrated invasive colonic adenocarcinoma, moderately differentiated. The patient was then referred to me for further surgical management. The risks, benefits, and alternatives of the procedure were discussed extensively with the patient and family. All of their questions were answered. They agreed to proceed.

DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was taken to the operating room. He was given perioperative IV antibiotics. He was then placed on the operating table in a supine position. Subcutaneous heparin was administered. Compression boots were applied. The patient then underwent general endotracheal anesthesia. A Foley catheter was then placed. The patient was then placed in the lithotomy position. The beanbag was then desufflated. He was then secured to the table. His abdomen was prepped and draped in the usual sterile manner. The umbilicus was opened with a #11 blade. Dissection revealed an umbilical hernia. The subcutaneous tissue was taken off the skin and the contents of the hernia were then placed back into the abdomen. Access to the abdomen was gained with blunt dissection. A single U-shaped 0 Vicryl suture was then placed into the fascia. A 12 mm trocar was then placed into the abdomen and gas insufflation was obtained.

Initial inspection of his abdomen revealed no abnormalities. His liver was examined and there was no evidence of metastatic disease. It was clear that this case was going to be difficult at this point in time as the patient was extremely obese in his abdomen. We then placed him in the Trendelenburg position and mobilized his small bowel out of the pelvis. We then began a dissection over the sacral perimeter beneath the IMA pedicle. This dissection was difficult as his mesentery was extremely thick and the small bowel would not stay out of the pelvis despite multiple maneuvers. I then felt that it was easier to perform a lateral dissection first. His sigmoid colon was then taken off the left pelvic sidewall carefully to preserve the underlying vascular structures as well as the ureter. This dissection was carried along the edge of the retroperitoneum as it attached to the colon, colon mesentery, and the sigmoid colon. This was then taken all the way up to the level of the splenic flexure. We then began our dissection over the distal transverse colon. The gastrocolic ligament was divided and access to the lesser sac was gained. The Harmonic scalpel was used to transect the omentum distally overlying the colon. We then carried this dissection up to the splenic flexure. We then fanned the splenic flexure out and mobilized carefully beyond this over the area of Gerota's fascia overlying the left kidney. This was mobilized all the way up to the level of the inferior border of the pancreas, where the inferior mesenteric vein was identified. We then carried this dissection back down towards the left pelvic sidewall. We identified the left gonadal vessels. Identification of the ureter was difficult because of his fatty tissues. We did eventually identify this and this was preserved and mobilized laterally away from the colon mesentery. We then performed dissection back from the medial side underneath the IMA pedicle leading across where the dissection had been performed laterally. The ureter was kept inferior. The proximal IMA was identified. A window above this was opened with Bovie electrocautery. The overlying peritoneum of the IMA was then opened with a combination of coagulation and Harmonic scalpel. We then transected the IMA carefully with the ligature device. Hemostasis was adequate at that time.

We then performed additional dissection medially up under the mesentery of the sigmoid colon again leading across Gerota's fascia and retroperitoneal structures, which had been mobilized inferiorly from the lateral aspect.  Once I felt that the splenic flexure was completely mobilized and that the mobility on the transverse colon, splenic flexure, and descending colon was adequate, we made a small lower midline incision. This was performed with Bovie electrocautery. The fascia was then divided, the midline was identified, and the perineum was then opened. The bladder was carefully mobilized laterally to avoid injury. A medium sized protractor drape was then placed into the abdomen. The colon was then removed from the abdomen. An area between the descending colon and sigmoid colon was identified and chosen as the area to be transected. The mesentery here was divided. The marginal vessels were identified and divided. The marginal vessel had good pulsatile bleeding. These were then clamped and secured with 0 Vicryl sutures. The bowel was then cleaned off and then transected with an automated purse-string device. The ILS-29 anvil was then placed into the descending colon and secured with the previously placed suture. This was then packed away as was the small bowel up into the abdomen, and the pelvic portion of our procedure was then performed.

We had already dissected over the sacral promontory in the presacral plane and this was continued distally with Bovie electrocautery. Care was taken to preserve the fascia appropriate to the rectum. The prerectosacral fascia was then divided to gain access below the level of the tumor. This tumor was palpable. We then performed the lateral dissection along the right and left pelvic sidewalls. Care again was taken to not injure either ureter or vascular structures, but provide adequate margin for our tumor. We then performed this dissection anteriorly as our lateral dissection met. The bladder and anterior structures were then mobilized away from the edge of the colon. Care was taken to preserve those anterior structures. I do not believe we reached the level of the seminal vesicles and they were thus preserved. Dr. Doe then performed proctoscopy to ensure we were well distal to our tumor and we were. The mesentery had thinned in this region and was taken along with the rectum with a single fire of the TX-60 stapling device. The specimen was then removed, opened, and examined along with pathology. The distal margin was approximately 2.6 cm. There was some fibrosis within the mesentery and there was some palpable lymphadenopathy. The abdomen was then irrigated copiously with saline solution. Hemostasis was adequate. We then performed the ILS-29 stapled colorectal anastomosis. There was absolutely no tension on the anastomosis. Hemostasis was adequate. The doughnuts were then examined and found to be complete. The anastomosis was then leak tested under water and there was no leakage. We had to remove the packing from the abdomen. We also removed the protractor drape.

At this point in time, all counts were correct. The fascia was then closed with running 1 PDS suture. The wound was then irrigated copiously with saline solution. The wound was then staple closed. The fascia at the umbilicus was closed with a single 0 Vicryl suture that had been previously placed. All the other trocar sites were then closed with single 4-0 Vicryl or 4-0 Monocryl suture. All the wounds were cleaned and dried and secured with Tegaderm and a sterile gauze dressing. The patient was then awakened, extubated, and taken to recovery room in good condition.

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Medical Transcription Orthopedic Surgical Procedure Transcribed Sample Report

PREOPERATIVE DIAGNOSIS:  Left rotator cuff tear.

POSTOPERATIVE DIAGNOSES:
1.  Left rotator cuff tear.
2.  Left labral tear, SLAP type 2.

OPERATIONS PERFORMED:
1.  Left arthroscopic rotator cuff repair with a double row fixation.
2.  Left arthroscopic subacromial decompression.
3.  Left arthroscopic SLAP type 2 repair.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Scalene block.

TOURNIQUET TIME:  None.

ESTIMATED BLOOD LOSS:  Less than 5 mL.

DRAINS:  None.

COMPLICATIONS:  None.

INDICATIONS FOR SURGERY:  The patient is a (XX)-year-old male who injured his left shoulder.  The patient was seen in my office, and after a detailed history, physical exam, review of plain film radiographs including an MRI scan, concerns of a rotator cuff tear was entertained. Because of continued pain complaints, despite physical therapy and corticosteroid injections, he presents now for above-mentioned operation.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room, and after scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a sitting position. Of note, preoperative antibiotics were given and the left shoulder was prescrubbed with Betadine. Next, the left upper extremity including the left base of the neck and shoulder was prepped and draped in the usual sterile fashion. After bony palpation, a posterior portal was created with a 15 scalpel blade and this was used for the arthroscope. The arthroscope was placed and a complete inventory of the left shoulder was performed.

Under direct visualization, an anterior superior portal was created in a similar fashion and this was used for outflow and instrumentation. A superior labral tear was noted at the base of the biceps anchor, which included the biceps anchor. This started at the 12 o'clock position and extended anteriorly to about the 10 o'clock position. There was fraying and this was debrided with a radiofrequency device, and with further probing, there was noted to be a lift off and therefore it was felt that this was a repairable construct. The rest of the anterior labrum, inferior labrum and posterior labrum were within normal limits. There was a negative drive-through sign. The articular surface of the glenoid fossa and humeral head were within normal limits. The axillary pouch showed no loose bodies. Mild form of neovascularization was noted in the rotator interval. There was no defect. The intraarticular subscapularis was within normal limits. The biceps was medialized. There was no evidence of fraying or delamination laterally. A large tear of the supraspinatus was identified with fraying. The posterior rotator cuff was within normal limits.

Under direct visualization, a trans-rotator cuff portal was created through the rotator cuff tear to help with instrumentation. The edge of the glenoid rim was decorticated with a 5.5 full radius shaver to bleeding bone. A 3.0 BioRaptor suture anchor was then placed at the base of the biceps. Utilizing arthroscopic knot tying techniques, the superior labrum was repaired with a #2 Ultrabraid in a sliding knot fashion. A fourth portal was then created at the anterior-inferior aspect and this was used just superior to the intraarticular subscapularis. This was used for instrumentation. Utilizing the double-armed suture anchor, the anterior aspect of the labrum was repaired in a similar fashion with #2 Ultrabraid in a simple half-hitch fashion. This secured the biceps anchor and with probing noted to have no evidence of liftoff. It was felt by the operative team that an adequate SLAP repair had been performed. The arthroscope was then placed into the subacromial region. Significant amounts of neovascularization with thickening of the subacromial bursa was identified.

Under direct visualization, a lateral portal was created in a similar fashion. A formal bursectomy was performed with a 5.5 full radius shaver as well as a radiofrequency device. Hypertrophic thickened coracoacromial ligament was identified and this was incised and released. A small enthesophyte was identified. A formal acromioplasty was performed with a 5.5 full radius shaver. Resection was carried to a smooth, flat surface. The arthroscope was then placed in direct lateral portal and visualization demonstrated a large rotator cuff tear, which measured almost 5 cm. This started anteriorly and extended posteriorly to just about the level of the infraspinatus. The edge of the greater tuberosity was decorticated with a 5.5 full radius shaver to bleeding bone. A 5.0 TwinFix suture anchor was then placed at the posterior aspect of the tuberosity near the rotator cuff.

Utilizing arthroscopic knot tying techniques, a rotator cuff repair was performed posteriorly with the double-armed TwinFix with #2 Ultrabraid in a simple half-hitch fashion. This repaired the posterior aspect of the rotator cuff. This converted the rotator cuff to a small crescent shape anteriorly. A second suture anchor was then placed at the articular margin at the medial footprint. Utilizing arthroscopic knot tying techniques, a mattress suture was passed and secured with #2 Ultrabraid in a simple half-hitch fashion. This now secured the entire medial footprint of the rotator cuff. A third 5.0 TwinFix suture anchor was placed more laterally, and with arthroscopic knot tying techniques, a simple suture was passed with the double-arm and secured with #2 Ultrabraid in a simple half-hitch fashion. This reconstructed the lateral footprint. With probing, there was now no liftoff and it was felt by the operative team that an adequate concomitant subacromial decompression and rotator cuff repair had been performed.

The instruments were removed and the portal sites were closed with 4-0 nylon in a simple interrupted fashion. All sponge and instrument counts were correct and estimated blood loss was less than 5 mL. The wounds were then cleaned and dressed under sterile field. A Polar Care ice machine and a shoulder immobilizer were placed to the left upper extremity. The patient was then escorted to the recovery room in a stable condition.

Psychiatry - Transcribed Medical Transcription Sample Report / Example

IDENTIFYING DATA:  The patient is a (XX)-year-old male.

CHIEF COMPLAINT:

1.  Bipolar affective disorder.

2.  Obsessive-compulsive disorder.

3.  Anxiety and depression.

HISTORY OF PRESENT ILLNESS:  According to the patient, he suffers from severe mood swings that alternate between depression and mania.  During depressive episode, he experiences depressed mood most of the day, nearly every day on irregular and persistent basis.  He experiences markedly diminished interest and pleasure in almost all pleasurable activities.  His appetite becomes very poor, and there have been times when he has lost more than 5% of his body weight.  He has difficulty sleeping.  He tosses sometimes all night.  He also experiences psychomotor agitation and becomes very irritable and unable to tolerate frustration.  He isolates himself and becomes easily fatigued, associated with loss of energy.  He also admitted to feelings of worthlessness and hopelessness with diminished attention and concentration.  He has recurring thoughts of death and recurrent suicidal ideation without a specific plan.  He also admitted to having episodes of bipolar illness that is characterized by manic episode.  During the manic episode, he experiences inflated self-esteem and ideation of grandiosity with decreased need for sleep.  He becomes more talkative than usual and has a pressure to keep talking.  He also experiences flight of ideas and has subjective experience that thoughts go racing very fast in his head.  He becomes easily distractible and unable to focus on any particular task.  He will engage in multiple tasks without completing any of the tasks.  He also experiences obsessive-compulsive symptoms.  He experiences recurrent and persistent thoughts, impulsive and immediate, that are experienced on a regular basis; most of the thoughts fixing on any particular item.

Any attempt from him to ignore or suppress the thoughts brings about considerable anxiety.  He was treated with Zoloft, Zyprexa, and Xanax.  He also admitted feeling very paranoid, suspicious, and guarded.  Of late, he was put on Celexa 20 mg in the morning and Seroquel 100 mg at night.  According to him, he continued to experience the symptoms of anxiety and depression.

PAST PSYCHIATRIC HISTORY:  He was admitted as an inpatient in the past.  He denied any past history of suicide attempt.

ALLERGIES:  None.

MEDICAL HISTORY:  He denied any head injury or seizures.

DRUG AND ALCOHOL HISTORY:  He admitted to abusing alcohol on a sporadic basis, and he experimented with heroin in the past.  However, it appeared he was not telling the whole truth about the extent of his drug and alcohol abuse.

FAMILY HISTORY:  He has a sister who is autistic and also suffers from ADHD and OCD.

PERSONAL AND DEVELOPMENTAL HISTORY:  The patient was born and raised in (XX).  He has (XX)th grade education. 

MENTAL STATUS EXAMINATION:  The patient is a (XX)-year-old Caucasian male who is fairly well groomed and appeared his stated age.  During the interview, marked psychomotor restlessness was observed.  He has difficulty maintaining adequate eye contact.  His speech has no coherence, spontaneous.  However, he was able to express himself verbally.  He described his mood as anxious.  Objectively, his mood is severely dysphoric.  His affect is restricted, despondent, and extremely agitated.  He has difficulty expressing spontaneous emotional reactivity.  His behavior is appropriate.  His memory is very poor for recent events.  He was however awake, oriented to time, place, and person.  His concentration and attention were both impaired.  He has difficulty doing serial 7s and he was unable to add or subtract figures without difficulty.  General level of intelligence and fund of general knowledge appears to be within normal limits.  His level of personal hygiene is fairly good.  He has difficulty communicating, clearly due to his anxiety level.  However, he was able to achieve goal directed ideas.  He denied any suicidal or homicidal ideation.  His level of abstract reasoning is fairly intact.  It was very difficult to maintain any form of rapport with the patient throughout the interview, and he has difficulty following directions.  He has present ideation of worthlessness and hopelessness.  He, however, denied any auditory or visual hallucination.  He was very much preoccupied about his symptoms.  He has very poor insight into the nature of his marijuana and alcohol abuse.

DIAGNOSTIC ASSESSMENT:

Axis I:            1.  Bipolar affective disorder type 1 with psychotic features.

2.  Obsessive-compulsive disorder.

3.  Mood disorder, not otherwise specified.

4.  Alcohol and marijuana abuse, currently in remission in a controlled environment.

Axis II:            Rule out antisocial and borderline personality disorder.

Axis III:           Denied.

Axis IV:          Psychosocial stressors.

Axis V:           Current Global Assessment of Functioning of 55-60.  Functioning with mild to moderate impairment in activities of daily living and in interpersonal relationships.

PLAN AND RECOMMENDATIONS:

1.  I discussed with the patient the entire spectrum of his symptomatology, the diagnosis, and the need for medication to be adjusted.  I also explained the risks and benefits of the proposed medications to the patient, which were fully comprehended by him.

2.  I started him on the following medications:

a.  Chlorpromazine 100 mg in the morning, 200 mg at night, to target his paranoia as well as irritability.

b.  Valproic acid 0.5 grams p.o. b.i.d. to control his mood swings.

c.  Celexa 40 mg in the morning for his anxiety and depressive illness.

3.  I ordered for complete metabolic profile and VPA level to monitor the level of the drug in his system.

4.  He will also undergo extensive psychological testing to map out his personality profile and overall psychopathology.

5.  Due to the severity of his current symptoms, the patient will be admitted for ongoing psychiatric care.

Psych Sample Report # 1     Psych Sample Report # 2     Psych Sample Report # 3

Psych Sample Report # 4     More Mental Status Terms

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