Medical Transcription Colorectal Operative Samples For Medical Transcriptionists:
OPERATION PERFORMED: Procedure for prolapsed hemorrhoids.
OPERATION IN DETAIL: The patient was taken to the outpatient operating room suite. While on the stretcher, general endotracheal anesthesia was performed. The patient was then placed on the operating table in prone jackknife position. The patient's buttocks and perianal regions were shaved. The buttocks were sprayed with benzoin and taped apart. The perianal region was then prepped and draped using aseptic technique. The clear anoscope with obturator was inserted in the patient's anal canal. Local anesthetic was then injected into the skin in four quadrants. A 2-0 silk suture was then placed through the anoscope into the skin, in the four quadrants, then tied in place. Then, the obturator was removed. The guide was inserted in the patient's anal canal. A 0 Prolene suture was placed about 3 cm above the dentate line in the posterior midline circumferentially around the anus. The PPH stapler was brought into the field, opened, anvil was inserted above the pursestring. The pursestring was then tied around the anvil. The suture was then delivered through the shaft of the stapler and tied. While applying traction on the suture, the PPH instrument was closed. Once completely closed, it was held in place for a minute, fired and then held in place for an additional minute and then slowly opened, turned and removed out of the anal canal without difficulty. The suture line was inspected. In the anterior midline, some bleeding was noted from the staple line. It was oversewn with 3-0 chromic catgut x2. Thus the staple line was inspected, good hemostasis was noted. The scope was irrigated with sterile water, and return was clear. Gelfoam followed by 4 x 4s, ABD and tape were applied. The patient was then placed on the stretcher, extubated and transported to the recovery room in stable and satisfactory condition.
OPERATION PERFORMED: Three-quadrant hemorrhoidectomy and rigid sigmoidoscopy.
OPERATION IN DETAIL: The patient was taken to the operating room, placed on the operating table in prone jackknife position. IV sedation was administered. The patient's buttocks and perianal regions were then shaved. The buttocks were sprayed with benzoin and taped apart. The perianal region was then prepped and draped using aseptic technique. A perianal block was then performed by injecting local anesthetic, circumferentially, around the anus to each side, left and right lateral positions. A rigid sigmoidoscopy was then carried out to about 20 cm, grossly unremarkable. Attention was then turned to the right posterolateral position. The external and internal hemorrhoidal group was elevated, retracted towards the midline. Elliptical incision encompassing perianal skin, external and internal hemorrhoidal group up to the anorectal junction was performed using Potts-Smith scissors. Care was taken not to injure the underlying internal sphincter, which was visualized intact throughout the procedure. Hemostasis was controlled using electrocautery. A suture of 4-0 Vicryl was placed at the apex. Mucosal edges, including portion underlying sphincter, was approximated using 4-0 Vicryl running continuous suture up to the dentate line. The dentate line was reapproximated and the mucosal skin distally was approximated with the same running continuous suture. The wound was inspected, good hemostasis was noted. The same procedure was then performed on the right anterolateral and left lateral position. Both were closed with 4-0 Vicryl in running continuous sutures. The wound was reinspected, good hemostasis was noted and Gelfoam followed by 4 x 4s, ABD, and tape were applied. The sponge, needle and instrument counts were reportedly correct. The patient tolerated the procedure well, was transferred onto a stretcher and transported to the recovery room in stable satisfactory condition.
DATE OF OPERATION: MM/DD/YYYY
1. Sigmoid stricture.
2. Colovesical fistula.
3. Radiation enteritis.
4. Ventral abdominal hernia.
Exploratory laparotomy, lysis of adhesions, low anterior resection including portion of the descending colon, stapled colorectal anastomosis, mobilization of splenic flexure, resection of small bowel x1 with stapled side-to-side anastomosis, diverting loop ileostomy, ventral abdominal herniorrhaphy and repair of colovesical fistula.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
INDICATION FOR PROCEDURE: This is an (XX)-year-old female who came in with anemia of unknown cause. On workup and colonoscopy, it was discovered that she had a stricture of her sigmoid colon with a lumen of approximately 5 mm. The stricture length was approximately 6 cm. The patient therefore needed a resection in order to prevent obstruction and emergent surgery.
DESCRIPTION OF PROCEDURE: The patient's abdomen and perineal area was prepped and draped in the usual fashion. We entered into the abdomen through a lower midline incision infraumbilical, and with the takedown of multiple adhesions between the omentum and the anterior abdominal wall, the patient's previous mesh was identified. Omentum was freed from this as well in order to permit full abdominal exploration. Multiple adhesions cementing the small intestine into the pelvis were sharply dissected with Metzenbaum scissors. Once this was finished, the Bookwalter retractor was put in place and the small intestine was packed out of the way. Two small subserosal tears were repaired with interrupted 0 Vicryl stitches. A large portion of the small intestine had identifiable severe radiation enteritis damage as well as a couple of serosal tears, and the mesentery and the small intestine were thickened in this area, and therefore, the decision was made that this should be resected later in the case for the patient's benefit. Once the small bowel was packed out of the way, retraction of the uterus and ovaries permitted sharp dissection and identification of the colovesical fistula, which appeared to be involving the proximal rectum/distal sigmoid colon. This was bluntly and sharply dissected away. The defect in the bladder was approximately 5 mm and this was closed with interrupted 4-0 Vicryl stitches. Methylene blue was instilled into the bladder and the bladder distended with no evidence of leak. The colon was then stapled with a TA stapler in order to keep stool from exiting out the colon side of the fistula, and the left colon and splenic flexure were mobilized using sharp dissection and the LigaSure in their entirety. The patient had multiple wide-based diverticula throughout her entire left colon, and therefore, decision was made that she would benefit by a high ligation just distal to the splenic flexure. This was done and the anvil end of a 29 EEA stapler was sewn in place and then this was also packed out of the operative field. The rest of the sigmoid colon and proximal rectum were sharply dissected using LigaSure with sharp dissection and suture ligation of the large arteries and veins. The lateral pedicles were mobilized using LigaSure down into the presacral space with a total mesorectal excision approximately at location of the middle rectum. The colon again felt soft and pliable and this area was cleaned of its mesentery and then stapled again with the TA stapler and the specimen was handed off. At this point, the left colon was brought down into the pelvis and it became apparent that the area that we had chosen still had a large amount of diverticula and could be safely resected and still allow for anastomosis without tension. Therefore, this was done and the anvil was again sutured into place. At this point, using a 29 EEA stapler, colorectal anastomosis was made. This was then completely oversewn with interrupted 3-0 silk Lembert stitches. The anastomosis was tested under water and showed no evidence of leak, and 2 complete doughnuts were sent off for pathology. At this point, the previously identified area of severe radiation enteritis of the small intestine was again identified and resected. The mesentery was taken with LigaSure and a new stapled side-to-side anastomosis was created with GIA 65 stapler and then the TA stapler across the spout, and the specimen also was handed off and sent to pathology. The staple lines were oversewn with interrupted 3-0 Lembert stitches and then the mesenteric defects were closed with a running 3-0 Vicryl stitch. The abdomen was then extensively irrigated and an area in the right lower quadrant over the rectus muscle was chosen for the patient's diverting loop ileostomy. A portion near the terminal ileum was identified and this was delivered up through the skin. A deep drain had been placed in the pelvis and brought up out the left lower quadrant and this was sutured into place with a drain stitch and the end of this was then cut off and placed as a loop around the loop ileostomy in order to facilitate it from retracting underneath the skin. The entire small intestine was then run and 2 other small serosal tears were identified and these were oversewn. There was another short area of radiation enteritis, although not as severe as the portion resected. There were no serosal tears identified and there were no other abnormalities of the small intestine noted. Therefore, we closed fascia and previous hernias that had been identified upon entering into the abdominal cavity with 2 running 0 Prolene stitches. Subcutaneous area was irrigated. Copious amounts of Seprafilm was placed underneath the fascia as well as around the loop ileostomy to facilitate further closure, and the skin was closed with skin staplers around a catheter that was subcutaneously placed to allow for irrigation with local anesthesia. The diverting loop ileostomy was stapled with the TA stapler and then matured in a standard Brooke fashion with interrupted 4-0 Vicryl stitches. Counts were correct at the end of the case. The patient tolerated the procedure without complications and was transferred to recovery in stable condition.
OPERATION PERFORMED: Lateral internal sphincterotomy.
DESCRIPTION OF OPERATION: After obtaining informed consent, the patient was taken to the operating room and placed on the operating room table in the prone jackknife position. All bony prominences were appropriately padded. The buttocks were then taped apart. The perineum was then prepped and draped in the usual sterile manner. Initial inspection of his anus revealed the posterior midline anal fissure after eversion of the anal canal. A digital rectal exam was then performed, which revealed tight internal sphincter muscle. His anus was injected with a total of 40 mL of 0.5% lidocaine with epinephrine. A medium-sized Hill-Ferguson retractor was then placed in the anus to help provide exposure for the left lateral internal sphincterotomy. A 1 cm incision was then made over the intersphincteric groove. A straight clamp separated the internal-external sphincter muscles. Allis clamp was used to grasp the internal sphincter muscle and bring it into the wound. This was then transected with Bovie electrocautery. Hemostasis was adequate. The wound was then closed with a 3-0 chromic suture. His anus was then injected with an additional 20 mL of 0.25% Marcaine solution. Bacitracin ointment was applied. The patient was then taken to recovery room in good condition.
PROCEDURES PERFORMED: Examination under anesthesia and placement of seton.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and given spinal anesthesia. He was then placed on the operating room table in the prone jackknife position. All bony prominences were appropriately padded. His buttocks were then taped apart. His perineum was then prepped and draped in the usual sterile manner. Initial inspection revealed two setons intact. Digital rectal exam was performed and revealed a soft pliable anus. There was no stricturing or scarring. Small-sized Hill-Ferguson retractor was then placed in the anus and the anus was then examined. There was no evidence of proctitis. A gently curved probe was used to identify the tract of the new external opening. This again entered the anus in the posterior midline. An additional seton was then placed and secured with 0 silk sutures. His anus was then injected with a total of 20 mL of 0.25% Marcaine solution. His anus was then cleaned and dried and sterile gauze dressing was then applied. The patient was then taken to the recovery room in good condition.
PROCEDURE PERFORMED: Excision and fulguration of anal condyloma.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and placed on the operating table in the prone jackknife position. Buttocks were then taped apart. His perineum was then prepped and draped in the usual sterile manner. His anus was anesthetized with a total of 40 mL of 0.5% lidocaine with epinephrine. The condyloma on the right side of his anoderm was identified, fulgurated, and gently debrided. His anus was then examined and there was no intra-anal component of the condyloma. Hemostasis was obtained. An additional 20 mL of 0.25% Marcaine was instilled into the perianal tissue. Bacitracin ointment and a sterile gauze dressing were then applied. The patient was then taken to the recovery room in good condition.
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