Supracervical Hysterectomy RSO Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Pelvic mass, suspected fibroid, ovarian cyst.
2.  Anemia.

POSTOPERATIVE DIAGNOSES:
1.  Pelvic mass, suspected fibroid, ovarian cyst.
2.  Anemia.

PROCEDURES PERFORMED:
1.  Exam under anesthesia.
2.  Exploratory laparotomy.
3.  Right salpingo-oophorectomy.
4.  Supracervical hysterectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  275 mL.

INDICATION FOR PROCEDURE:  This is a (XX)-year-old multigravida female with four prior cesarean sections, who was noted to have anemia and an enlarged uterus compatible with fibroids and a possible right ovarian mass. Secondary to this, it was felt the above procedure was indicated, and the patient gave her informed consent for surgical management.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the supine position. She underwent general endotracheal intubation without complication. The patient was placed in the frog-leg position. An exam under anesthesia revealed a 14-16 week size anterior uterus that was irregular in shape. The patient was then prepped and draped in the usual fashion for the procedure. Thromboguards were placed on her lower extremities bilaterally, and a Foley catheter was anchored to closed gravity drainage.

The prior vertical skin scar/incision was sharply dissected and excised with scalpel. This incision was carried down to fascia with a deep knife. The fascia was incised in the midline and extended cephalad and caudad with Mayo scissors. The peritoneum was identified, elevated and entered with Metzenbaum scissors. Upon entering the peritoneal cavity, pelvic washings were obtained.

Examination of the upper abdominal cavity revealed a smooth liver edge and diaphragm. The lower poles of the kidneys were palpated and felt to be within normal limits. No retroperitoneal lymphadenopathy was noted. There was a 5 cm right adnexal cyst that appeared to be compatible with a dermoid or fibroma and a 16-week size uterus, which contained fibroids.

Hysterectomy was carried out by double clamping the round ligaments, excising with the scalpel and ligating with 0 Vicryl suture. The right anterior and posterior sheaths of the broad ligament were sharply incised with curved Mayo scissors and the retroperitoneal space developed with blunt dissection. The ureter was palpated. A rent was made superior to this in the posterior aspect of the broad ligament. The infundibulopelvic ligament was triply clamped and excised with the scalpel, ligated first with a free tie of 0 Vicryl suture followed by a modified figure-of-eight stitch. The uterine vessels were skeletonized. The left round ligament was doubly clamped and excised with the scalpel.

The anterior leaf of the broad ligament was incised sharply with Metzenbaum scissors. The retroperitoneal space was developed. She had a normal left tube and ovary. The round ligament, utero-ovarian ligament and fallopian tube were triply clamped and excised with a scalpel. The pedicle was ligated first with a free tie of 0 Vicryl suture followed by a modified figure-of-eight stitch. These uterine vessels were then skeletonized.

The cervicovesical space was then sharply developed. The uterosacral ligaments were doubly clamped with curved Heaney clamps. The pedicles were formed with the scalpel and ligated with 0 Vicryl sutures bilaterally. Hysterectomy was then carried out with straight Heaney clamps, forming the pedicles, excising them with the scalpel and ligating them with 0 Vicryl suture. Secondary to the depth of the pelvis and the length of the cervix, it was felt that a supracervical hysterectomy was indicated, and the cervix was then surgically amputated with both sharp and Bovie cautery. The angles were ligated in modified Heaney stitch fashion incorporating the uterosacral ligaments bilaterally. The cervix was then oversewn with figure-of-eight 0 Vicryl sutures. The specimen was handed off and sent to pathology for histopathologic confirmation.

Irrigation was used and hemostasis confirmed. The moist laparotomy sponges were removed. The parietal peritoneum was closed with running 3-0 Vicryl suture. Again, irrigation was used and hemostasis confirmed. The abdominal fascial edges were closed with interrupted 0 Vicryl sutures. Again, irrigation was used and hemostasis confirmed. The subcutaneous tissues were closed with interrupted 3-0 Vicryl sutures. An additional layer of a running subcuticular stitch was placed with 3-0 Vicryl suture, and the skin edges reapproximated with staples. A sterile dressing of Telfa and was applied.

 The patient was taken to the recovery room awake and alert and extubated. There were no intraoperative complications. The patient had Thromboguards on her lower extremities and a Foley catheter anchored to closed gravity drainage. The patient will have a PCA pump for postoperative analgesia.

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Supracondylar Humerus Fracture ORIF MT Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left humerus fracture.

POSTOPERATIVE DIAGNOSIS:  Left humerus fracture and left supracondylar humerus fracture.

OPERATION PERFORMED:
1.  Open reduction and internal fixation of left supracondylar humerus fracture.
2.  IM nail with cerclage wiring of left humerus fracture.

SURGEON:  John Doe, MD

Treatment options were discussed with the patient including closed reduction and coaptation splint treatment.  This was attempted on the floor.  The patient was given 4 mg of morphine, and under conscious sedation, a coaptation splint was obtained with still approximately 45 degrees of varus deformity of humerus fracture.  After full discussion with the patient and risks and benefits of intramedullary nail to the left humerus were discussed with her, the patient wished to proceed with the surgery.  She understood particularly the risk of infection, nerve injury, malunion, nonunion, loss of motion and strength, and loss of normal function of the shoulder or elbow.  We also explained that there was a significant anesthetic risk to her heart and lungs and risk of severe bleeding because of her low platelet count and cirrhosis leading to platelet dysfunction.  The patient understood all these risks and wished to proceed with surgery.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the supine position.  She was administered general anesthesia and prepped and draped in the usual sterile fashion.  An incision was made over the lateral aspect of the arm, approximately 2 cm from the acromion, splitting through the skin down to the fascia overlying the deltoid.  The fascia overlying the deltoid was split in longitudinal fashion and, through blunt dissection, it was taken down directly to the humeral head over the greater tuberosity.  The rotator cuff was identified and was not violated throughout the entirety of the case.

An awl was placed in the greater tuberosity of the humeral head, and a guidewire was introduced into the humerus.  The fracture was reduced with the use of fluoroscopy.  Once fracture reduction was confirmed on both AP and lateral views, fluoroscopically assisted ruler was used to measure the diameter and length of the screw.  A 7.5 mm in diameter, 225 mm long flexible Synthes intramedullary humeral nail was inserted.  This was inserted, with fluoroscopy, through the fracture site and down to the distal humerus.  At this time, the humerus proximally and distally both viewed in multiple views in the AP and lateral planes, and there was no identifiable fracture.  A proximal locking screw was then placed through a small stab incision through the lateral aspect of the arm.  A hemostat was used to spread through the muscle tissues and protect any potential neurovascular structures underneath.

Once the locking screw was placed, the proximal locking screw was placed into the intramedullary nail.  After completion of this, the elbow was gently straightened for insertion of the distal locking screw, and an audible and palpable clunk was heard.  X-rays at this time revealed a supracondylar humerus fracture.  The supracondylar humerus fracture was then reduced openly through a triceps-splitting approach posteriorly.  An incision was made from the tip of the olecranon proximally.  This was taken through the skin and subcutaneous tissues down to the triceps.  The triceps fascia was split longitudinally and triceps muscle was split in its mid belly to reveal the fracture.  Because of the fracture plane and the previous nail, the previous nail was keeping the supracondylar humerus fracture from being properly reduced, a Midas saw was used to saw off the distal portion of the intramedullary nail through the locking holes, and a reduction was then obtained of the supracondylar humerus fracture and two interfragmentary lag screws were placed with 3.2 cortical screws through an oblique fracture line in the supracondylar humerus.  This fracture line was then further stabilized by the use of an 8-hole Synthes, 3.5 mm LC-DCP locking plate.  Two distal locking screws were placed in the distal fragment followed by three standard screws with Synthes cable fixation proximally.

We were unable to secure further fixation because of the previous intramedullary rod.  This was discussed with the surgical team, and it was felt best to leave the intramedullary rod to further stabilize the proximal fragments.  Fluoroscopy was then again used to confirm reduction of the elbow in both the AP and lateral planes.  Final x-rays were taken proximally, which then showed that the lateral cortex, with holding in the intramedullary nail, had blown out due to severe osteoporosis of the left proximal humerus.  An incision was then made extending the initial incision from the entrance of the intramedullary nail to the proximal locking screw.  This incision was then taken again through deltoid splitting in a longitudinal incision.  Great care was made to ensure and identify that there was no axillary nerve in the surgical field.  Two Zimmer cables were placed proximally to secure the intramedullary nail into the blown out lateral cortex and to reduce the blown out lateral cortex fragments.  Blunt dissection was used for placement of these proximal cables around the bone to ensure that the radial nerve was protected within the spiral groove at all times and the cable was not placed on or near the radial nerve.

Once again, fluoroscopy was used to confirm reduction.  Adequate reduction was confirmed throughout the shoulder, mid humerus, and elbow in both the AP and lateral planes.  The wounds were then vigorously irrigated.  Fascia overlying the triceps and deltoid were both repaired with 0 Vicryl suture followed by 2-0 Vicryl suture subcutaneously and staples for the skin.  The wounds were covered with Xeroform gauze, 4 x 4's, and Webril.  A post-mold plaster cast splint was placed over the left arm and wrapped with sterile Webril and Ace bandage.  The patient awoke from anesthesia in stable condition and was transferred to the recovery room.  Total intraoperative use of blood products included 1 unit of packed RBCs.  The patient also received platelet transfusion during the case.  The patient's vitals are completely stable.

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Bunionectomy Kidner Procedure Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left hallux abductovalgus.
2.  Left accessory navicular bone.

POSTOPERATIVE DIAGNOSES:
1.  Left hallux abductovalgus.
2.  Left accessory navicular bone.

OPERATION PERFORMED:
1.  Left bunionectomy with first metatarsal osteotomy and screw fixation.
2.  Left Kidner procedure.

SURGEON:  John Doe, MD

ANESTHESIA:  Local with MAC.

HEMOSTASIS:  Left pneumatic ankle tourniquet set at 250 mmHg.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

MATERIALS:  Two 2.0 AO cortical screws.

INJECTABLES:  20 mL of 50:50 mixture of 1% lidocaine plain and 0.5% Marcaine plain.

COMPLICATIONS:  None.

INDICATIONS FOR OPERATION:  This is a (XX)-year-old female patient who has been experiencing left bunion and left navicular/midfoot pain for quite some time.  The patient has attempted conservative measures, which have all failed.  The patient opts for surgical correction at this time.  The patient has been medically cleared.  The patient has signed consent for surgery, and the patient confirms n.p.o. status since last midnight.  The patient understands the risks and benefits of surgical correction as explained preoperatively.

DESCRIPTION OF OPERATION:  Under mild sedation, the patient was brought to the operating room and placed on the operating room table in the supine position where a well-padded left pneumatic ankle tourniquet was placed.  Next, the above-mentioned cocktail was injected in a Mayo block fashion in and about the left foot navicular bone.  The foot was then prepped and draped in the usual aseptic manner.  The foot was then elevated at an approximately 45-degree angle for about 4 minutes and then the tourniquet was inflated to 250 mmHg.

Attention was directed to the first metatarsophalangeal joint where approximately a 6 cm dorsal linear incision was made medial and parallel to the extensor hallucis longus tendon.  Sharp and blunt dissection was carried down through the subcutaneous tissues, retracting all neurovascular structures and ligating all necessary bleeders.  Next, dissection was utilized medially to free up all subcutaneous tissue layers off of the medial capsule.  Next, dissection was carried down into the first intermetatarsal space were a lateral release was performed by transecting the deep transverse metatarsal ligament, conjoined tendon, fibular sesamoidal ligaments, followed by a lateral capsulotomy.  The hallux was put into a transverse plane range of motion, and it was noted that adequate release was accomplished.

Next, an inverted type capsulotomy was performed.  All periosteal tissue layers were freed up with a Freer elevator.  All soft tissue attachments were reflected off the medial eminence.  The medial eminence was then resected with an oscillating saw.  Next, a 0.045 K wire was inserted directly medially into first metatarsal head for slight elongation and mild plantar flexion.  A twice as long dorsal chevron osteotomy was then performed with the oscillating saw.  The K-wire was removed and the capital fragment was translocated laterally into a corrected anatomical position.

Next, two 2.0 AO cortical screws were inserted across the osteotomy site using strict lag screw technique.  Fluoroscopy was utilized to confirm proper screw fixation, and it was noted to be in excellent position.  Next, all redundant medial capsular tissue was removed.  The wound was flushed and irrigated using copious amounts of normal sterile saline.  Deep closure of the capsule was done and reapproximated using 4-0 Vicryl suture.  The skin was closed and reapproximated using 5-0 Prolene suture in a horizontal mattress interrupted suture technique.

Attention was then directed to the medical aspect of the midfoot where approximately a 5 cm slight S-type incision was made about the navicular tuberosity.  Sharp and blunt dissection was carried down through the subcutaneous tissues, retracting all neurovascular structures and ligating all necessary bleeders.  Dissection was carried down to the posterior tibial tendon sheath where it was carefully incised and was tagged for later closure.

Next, the posterior tibial tendon was identified as attachment at the navicular tuberosity.  An incision was made through the superior aspect of the tendon and freed off of the navicular.  Fluoroscopy was utilized to visualize the os navicularis.  The accessory bone was then removed with an oscillating saw and osteotome.  It was noted that the bone had a blackish discoloration appearance and a segment of bone was sent for pathology.

Following removal of the accessory bone, the wound was flushed and irrigated using copious amounts of normal sterile saline.  The tendon was reapproximated using Vicryl suture and the remaining deep closure was reapproximated with 4-0 Vicryl suture.  Next, the skin was closed and approximated using 4-0 Prolene suture in a horizontal mattress interrupted suture technique.  All wounds were dressed with Steri-Strips, Betadine-soaked Adaptic, 4 x 4, Kling, and an Ace bandage.  The tourniquet was deflated.

The patient tolerated the anesthesia and procedure well and returned to the PACU with vital signs stable and hyperemia noted to all left foot digits.

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Low Anterior Resection Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Recurrent sigmoid diverticulitis.
2.  Retroperitoneal cyst.
3.  Umbilical hernia.

POSTOPERATIVE DIAGNOSES:
1.  Recurrent sigmoid diverticulitis.
2.  Retroperitoneal cyst.
3.  Umbilical hernia.

OPERATION PERFORMED:
Open low anterior resection, repair of umbilical hernia.

SURGEON:  John Doe, MD

ANESTHESIA:  General.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old male who has had four documented episodes of diverticulitis on CAT scan.  He is now recommended to undergo elective sigmoid resection.  Recent CT scan was also noted to have a retroperitoneal cyst in the retrocecal area.  We decided to explore this as well.

FINDINGS AND DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient was taken to the operating room and placed in the supine position.  After adequate induction of general anesthesia, he was placed in the lithotomy position.  Sequential compression devices, TED stockings, and Foley catheter were placed and intravenous antibiotics were administered.

A rigid proctosigmoidoscopy was first performed, and the rectum was cleared of stool.  A vertical midline incision was then made up to the umbilicus.  Dissection was carried through the subcutaneous tissue down to the fascia, which was dissected sharply and opened for the length of the incision.

A Bookwalter retractor was assembled.  The abdomen was then explored.  The small bowel was normal.  Noted that the sigmoid was not attached to the normal lateral pelvic and lateral sidewall.  The entire mesosigmoid was actually within the midline of the abdomen and the tenia densely adherent to the root of the small bowel mesentery.  The small bowel was packed out of the way.  The sigmoid was then carefully mobilized off of these mesenteric attachments until it was completely free.

As noted again, there were absolutely no attachments to the lateral sidewall.  The cecum was first mobilized.  The retroperitoneal binder was explored.  There was no obvious mass or cyst in this location.  The sigmoid was very redundant.  There were multiple loops of redundant sigmoid and one which was densely adherent to the lateral pelvic sidewall.  It was firm and indurated here and clearly a site of prior perforation.  This was taken off sharply.

At this point, this site was chosen for the proximal resection margin.  There was healthy bowel with very mild diverticular disease.  The bowel here was divided with an auto purse stringer.  The anvil of a 29 mm stapler was then placed and secured.  The mesentery was divided with LigaSure device.  Because there was so much redundant sigmoid and because of the abnormal attachments, we did not even have to take the inferior mesenteric pedicle.  We came down on the medial side of it with the LigaSure device.

We did divide the superior rectal artery, which was ligated with 2-0 Vicryl suture.  The hypogastric nerves were identified and preserved.  The presacral space was entered.  Below the sacral promontory, the mesorectum was then clamped and divided and ligated with LigaSure device and 2-0 Vicryl sutures.  This site was chosen for division of the rectum.  The TA60 stapler was fired.  The specimen was then passed off for further pathologic evaluation.

The abdomen was then thoroughly explored again.  Hemostasis was achieved.  The left ureter was identified.  Where we had taken off of the pelvic sidewall, we took some peritoneum with it.  We therefore gave an amp of indigo carmine with no extravasation.  The anastomosis was then performed with transanal end-to-end anastomosis using 29 mm stapler.  On insufflation of the anastomosis, there was a very small air leak anteriorly.  The anterior staple line was therefore oversewn with interrupted sutures of 4-0 silk.

Through a separate stab incision in the right lower quadrant, a 10 mm Jackson-Pratt drain was brought through and placed in the pelvis.  The abdomen was thoroughly irrigated with antibiotic solution.  Seprafilm was placed in the subfascial location.  The fascia was closed with a running continuous suture of looped #1 PDS repairing the umbilical hernia at the same time.

The subcutaneous tissue was irrigated with antibiotic solution.  The skin was closed with skin clips.  The patient tolerated the procedure well.  There were no complications.  Postoperatively, he was extubated and transferred to recovery room in stable condition.

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