General Surgery Medical Transcription Sample Reports For Medical Transcriptionists:
OPERATION PERFORMED: Left axillary sentinel lymph node biopsy and left partial mastectomy.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. Following induction of general anesthesia, the left breast and left axillary regions were prepped with Betadine and draped sterilely. Prior to prepping, the region of the outer aspect of the areola was injected in the subareolar region with 1 mL of 1% Lymphazurin blue. The breast was then gently massaged for several minutes and then routine prep continued. Following prepping and draping, the Neoprobe was brought on the field. The counts about the infection site and the subareolar region were in the range of 2000 and a sentinel node that had been marked had counts about 20 or 30 at the skin level. Then, 0.5% Marcaine with epinephrine was instilled into the region overlying the marking and a semilunar incision was made about 4 cm in length overlying the mark at the lower border of the axillary hair. Dissection was then carried down through the skin and subcutaneous tissue. Bleeders were cauterized. The wound was then deepened until the clavipectoral fascia was encountered and this was incised with cautery. The blue lymphatics were immediately identified and traced to a lymph node, which also was blue. The Neoprobe overlying this node revealed her to have counts in the range 80 to 90. The node with an adjacent one to it was taken out in its entirety and ex vivo counts over this noted revealed it to be 230. The background counts and the remainder of the axilla were all less than 8; therefore, no further lymphatic tissue was removed. The clavipectoral fascia was closed with several interrupted 4-0 Vicryl sutures and further Marcaine was instilled into the region. The skin was then closed with interrupted 4-0 Vicryl to the subdermal tissues followed by subcuticular running 5-0 Monocryl and Steri-Strips. Attention was then paid to the outer aspect of the left breast where she had obvious dimpling with probable dermal involvement of the underlying tumor. Elliptical skin markings were made about this to include it in specimen and an incision was made above and below this dimpled area occupying the outer aspect of the breast. Incisions were then made and carried down to just beneath the skin. The skin was then circumferentially undermined for additional 1.5 cm using the cautery unit. A generous portion of tissue was then removed staying at least 1 cm, palpable, away from the firm mass in the center of the specimen. This mass was taken down through the pectoral fascia and then excised off that. Once removed, it was oriented with a short suture on the superior margin and a long suture on the lateral margin. The specimen was sent to pathology. The specimen of the sentinel node at the conclusion of its removal was also sent to pathology, which revealed no evidence of any metastatic disease within it. Following removal of the breast tissue as mentioned, the area was checked for bleeding and none was apparent. The wound was then further instilled with Marcaine and closed in layers with interrupted 4-0 Vicryl to the subdermal tissues followed by subcuticular 5-0 running Monocryl and Steri-Strips. The patient was then dressed with sterile bandage and awakened and returned to recovery in good condition.
OPERATION PERFORMED: Laparoscopic cholecystectomy.
OPERATION IN DETAIL: The patient was placed on the operating table in the supine position. General anesthesia was induced. Endotracheal tube was used. A Foley catheter was placed. The abdomen was prepped with DuraPrep and draped. A 10 mm vertical incision was made in the base of the umbilicus. A Veress needle was advanced down and the abdomen was insufflated. A 10 mm trocar was placed and the scope was advanced down through here. The patient had numerous adhesions between the liver and the anterior abdominal wall and diaphragm. A 10 mm trocar was placed in the mid epigastrium and 5 mm trocars in the right midclavicular and anterior axillary lines. We took down the adhesions in the right upper quadrant just so that when we elevated the gallbladder we would not tear the liver capsule. The gallbladder was then grasped and then pulled up into the right upper quadrant. The second one was placed in the infundibulum. Dissection was begun in the area and the infundibulum taken down to the cystic duct. The cystic artery was identified, doubly clipped proximal, one distal and divided. The cystic duct was doubly clipped distal, one proximal and then divided. The gallbladder was dissected out of the liver bed using electrocautery without a lot of difficulty. It was placed in the right upper quadrant. The area was irrigated, suctioned dry, little bleeders were coagulated, again suctioned dry. The gallbladder was delivered out through the umbilical port. It had multiple stones. The gallbladder bed was rechecked. There was no drainage or bleeding and the trocars were removed. The abdomen was deflated with a Valsalva maneuver and the fascia of the umbilical port site was closed with interrupted 0 Vicryl. The skin of all four was closed with running subcuticular stitch of 4-0 Vicryl. Steri-Strips were placed on the skin, and Band-Aids over that. Foley catheter was removed. The patient was awakened, extubated, and taken to the recovery room.
OPERATION PERFORMED: Laparoscopic appendectomy.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed on the operating table in the supine position. General anesthesia was induced and the patient was intubated. He was administered Ancef and Flagyl IV and his abdomen was clipped of hair and prepped and draped in the standard sterile fashion. A curvilinear infraumbilical 10 mm incision was made and this was taken down to the fascia, which was grasped, elevated and divided in the midline. Stay sutures, 0 Vicryl, were placed. The peritoneum was opened bluntly and a finger sweep revealed no nearby adhesions. A 11 mm Hasson trocar was placed through this port and the abdomen was insufflated and surveyed. Survey of the right lower quadrant revealed some injection of the small bowel. The terminal ileum appeared normal. The appendix appeared acutely inflamed with some separation, but did not appear gangrenous or perforated. To continue working, two separate 5 mm ports were placed, one in the suprapubic region and one in the patient's right lower quadrant. The appendix was grasped and was elevated. We dissected the base of the appendiceal mesentery isolating this from the appendix itself. We switched to a 5 mm camera and introduced an Ethicon Endo GIA stapler. A blue load was used to transect the base of the appendix at the cecum. The mesoappendix was then taken with a vascular load of the stapler. The appendix was placed into an EndoCatch bag and was brought out through the umbilical trocar site. The trocar was replaced and the abdomen was re-surveyed. There was a small amount of blood surrounding the base of the mesoappendix. This was sectioned free. We observed this area for recurrence. We did not find any recurrence of the bleeding. There was no evidence of bleeding. Once we had assured ourselves that excellent hemostasis had been obtained, the abdomen was desufflated under direct vision and the trocars were withdrawn. The infraumbilical incision was closed with 3-0 Vicryls as were the two 5 mm port sites. Each of the skin sites were then closed with Dermabond. The patient tolerated the procedure well. He was extubated in the operating room and transferred to the recovery room in stable condition under the care of Anesthesia and surgical staff. There were no complications.
2. Therapeutic bronchoscopy.
DESCRIPTION OF PROCEDURE: On the day of the procedure, the patient remained in the neurosurgical intensive care unit. He was placed on 100% FiO2 and the bag-mask was prepared. The patient was placed on a shoulder roll with his neck extended. From the patient's anatomy, we were concerned that this would be a difficult intubation, and thus, the bronchoscope and the difficult airway devices were all available prior to beginning this. The patient was assisted with bag-mask ventilation and gentle cricoid pressures held. With saturations in the 100%, he was sedated with 20 mg of etomidate followed by 10 mg of vecuronium for chemical paralysis. Once he had ceased spontaneous respiratory effort, we continued respirations by bag-mask with saturations in the 100%. With cricoid pressure in place, a direct laryngoscope was then used to perform direct laryngoscopy. The epiglottis appeared swollen and it was difficult to visualize the cords. An endotracheal tube could not be passed at this point. The patient was noted to desaturate and had a desaturation event into the 70s. This was immediately remedied by bag-mask ventilation and cricoid pressure, which brought the saturations back up to 100%. We then again performed direct laryngoscopy visualizing what appeared to be a swollen epiglottis. At this point, the portion of the cords could be seen and Eschmann obturator was passed into the trachea. This was then followed with a 7.5 endotracheal tube, again using direct laryngoscopy to assist the Eschmann obturator through the cords. Air position was immediately confirmed by insertion of bronchoscope, which noted that the patient was right main stem intubated. The endotracheal tube was then withdrawn into the main trachea, so that the hilum was visible. The cuff was then inflated, and the patient was continued with bag ventilation and then attached to the ventilator. Once we had secured adequate airway, we carried out immediate bronchoscopy. The patient was noted to have no mucous plugging at the level of the segmental bronchi; however, he had thick tenacious secretions at the carina, especially in the right main stem bronchus. His airways also appeared swollen and injected consistent with tracheobronchitis. The airways were completely suctioned free of secretions and then the bronchoscope was removed. Prior to removing this, we viewed the orifices, each of the 19 pulmonary segments on both the right and left sides and terminals of these were free. No significant plugs. The procedure was then terminated and the patient remained in the neurosurgical intensive care unit in critical condition with saturations at this point of 100%.
OPERATION PERFORMED: Left breast lumpectomy and left axillary sentinel node biopsy.
DESCRIPTION OF OPERATION: The patient previously underwent needle localization of the left breast mass as well as lymphoscintigraphy. The patient was brought to the OR and placed in supine position. After induction of general anesthesia, she was prepped with ChloraPrep and draped in sterile manner. Three mL of methylene blue was injected into the breast tissue. We chose to inject the dye medial to the actual tumor site, as the tumor was located in upper outer quadrant of the left breast. Subdermal injection was avoided because of case reports of skin necrosis associated with methylene injection. A Neoprobe was brought to the field and localization of the probable site of the sentinel node was accomplished with the Neoprobe. A curvilinear 4 cm incision was made over this site. Dissection was carried down below the deltopectoral fascia exposing blue lymphatic channels. By tracing these, we did identify a single sentinel node measuring approximately 1 cm in size. Lymphatics going into and out of this site were ligated with 3-0 silk sutures and the specimen was removed. Counts of the specimen on table were approximately 126,000. Residual counts of the axilla were noted to be 50. Closure of this wound was achieved with 3-0 Vicryl for the subcutaneous tissues and running subcuticular 4-0 Monocryl for the skin. Steri-Strips and a Tegaderm dressing were applied. Gloves were changed and attention was turned to the lumpectomy site. Location of the mass was confirmed on intraoperative ultrasound using an Aloka T probe. We confirmed the direct placement of the wire into this area. The lesion was approximately 1.5 cm deep to the skin at its deepest level. A curvilinear incision was made along the skin lines of the breast over this site. Skin flaps were developed in both directions. A 4.5 cm mass of breast tissue was then excised with the mass centered within it. At the depth of the wound, we dissected the tissue planes anterior to the pectoralis fascia leaving the pectoralis fascia intact. The specimen was oriented with short stitch superior and long stitch lateral and it was sent off the field for pathologic examination. Careful hemostasis was achieved of the lumpectomy cavity. Subcutaneous tissues were approximated with 3-0 Vicryl and skin was closed with running subcuticular 4-0 Monocryl. Sterile dressings were applied. The patient tolerated the procedure well.
PROCEDURE PERFORMED: Percutaneous endoscopic gastrostomy tube placement.
DESCRIPTION OF PROCEDURE: The patient’s abdomen had been previously prepped and he had previously undergone a tracheostomy tube placement. The Olympus flexible endoscope was advanced through the oropharynx, past the epiglottis, and into the upper esophagus. It was then advanced into the stomach, which was insufflated with air. The pylorus was identified and intubated, and we surveyed the second portion of the duodenum and the duodenal sweep. These were each normal. The stomach was normal on retroflexed view. There was no hiatal hernia. The gastric mucosa appeared normal. The patient's stomach was then fully insufflated with air until the rugae were flattened. Palpation was then carried out in the patient's left upper quadrant. The patient was placed in 40 degrees of reverse Trendelenburg. This spot, where we had palpated, was transilluminated and was noted to transilluminate easily. The local needle was then passed through the patient's skin through his abdominal wall and directly into the stomach. There was no air that was found by aspiration along this route, and it was noted to enter easily into the patient's abdomen. This was then replaced by the introducer needle, and likewise, there was no air aspirated along the tract until the tip of the needle was seen in the stomach. The guidewire was then placed through the introducer needle and was grasped with the endoscope and was withdrawn through the patient's mouth. A Ponsky PEG tube was then attached to the guidewire and then returned in an antegrade fashion through the patient's esophagus and out the gastric wall through a stab incision. The endoscope was re-advanced into the stomach and the stomach was surveyed. There was no bleeding that was seen. The PEG tube was withdrawn until it reached a depth of 3 cm. At the depth of 3 cm, it was seen not to blanch the gastric mucosa, yet not appear to be too loose. This appeared to be appropriate placement for the PEG tube. It was cut to size and secured in place at this length. The endoscope was then withdrawn. On survey in the esophagus on the way out, no lesions were seen of the esophagus. A small amount of old blood from the previous biopsy was noted. The scope was then withdrawn after desufflating the stomach and the procedure terminated. The patient tolerated the procedure well and was taken to the recovery room under the care of Anesthesia and the surgical staff at the termination of the case. There were no complications.
PROCEDURE PERFORMED: Right cervical lymph node biopsy.
DESCRIPTION OF PROCEDURE: Intravenous sedation was provided. The right neck was extended and appropriately prepped and draped in the usual sterile fashion. Local anesthesia was provided with 0.25% Marcaine with epinephrine and a 50:50 mixture with 1% Xylocaine plain. The incision was 4 cm long on the anterior border of the sternocleidomastoid muscle on the right. This surgical incision was chosen because I do not want to be posterior to the sternocleidomastoid muscles and I do not want to risk any injury to the spinal accessory nerve. The incision was carried through the skin and subcutaneous tissues as well as the platysma muscle. The platysma was divided with electrocautery. The sternocleidomastoid muscle was mobilized with electrocautery and retracted laterally. Immediately underneath the sternocleidomastoid muscle, there was a large conglomeration of lymph nodes. They are hard, firm, fibrotic, and reasonably thick. One of these lymph nodes at the superior and lateral portion was able to be mobilized off of the chain of lymph nodes. Hemostasis was achieved with 3-0 silk ties. The specimen was removed and sent for pathologic analysis. Analysis by the pathologist describes the lymph node as being pathologic, atypical, and sufficient for diagnosis. Additional specimen was sent. Hemostasis was achieved with electrocautery. Hemostasis was complete. The platysma was closed with 3-0 Vicryl. The skin was closed with a 4-0 Monocryl subcuticular closure. Sterile dressings were applied. Sponge, needle, and instrument counts were correct. The estimated blood loss was less than 2 mL. The patient tolerated the procedure well and will be transferred to the recovery room
OPERATION PERFORMED: Laparoscopic appendectomy.
DESCRIPTION OF OPERATION: The patient was given intravenous antibiotics in the emergency room. After consent was obtained from the patient, he was taken to the operating room and placed supine on the operating table. After general anesthesia was established, Foley catheter was inserted and the abdomen was prepped and draped surgically. After the insufflation, 0.5% Marcaine with epinephrine was injected into the supraumbilical area and a 12 mm incision was made down through the subcutaneous tissue and the fascia was then grasped with two penetrating towel clamps. With upward traction, the Veress needle was inserted. A pneumoperitoneum was created with the insufflation of carbon dioxide to 15 mmHg. A 10 mm 0-degree scope was then inserted and the abdomen was examined. Liver, stomach, and the ascending colon all appeared grossly normal. There was purulent fluid located in the right lower quadrant. No evidence of fecal peritonitis is noted. Two additional ports of 5 mm ports were placed, one in the midline in the suprapubic area, in a similar fashion under direct vision, after the insufflation of 0.5% Marcaine with epinephrine and an additional port in the left lower quadrant. The teniae coli of the cecum was then followed down to the base of the appendix. The base of the appendix could be dissected out and then the appendix, which was in the retrocecal position, was gently dissected out with the combination of blunt and sharp dissection freeing up the adhesions and taking down the phlegmon, which had a wall of the terminal ileum and the fold of Treves. Once the window was created at the base of the appendix, an endovascular GIA 35 mm stapler vascular wire was fired across and transected the appendix at the base. The mesoappendix was further dissected off from the phlegmon, and once the appendix was adequately mobilized, the Endo-GIA was reloaded and fired across the mesoappendix. The appendix was then placed in an Endocatch bag and brought out through the umbilical port. The area was then irrigated with copious amounts of warm normal saline. The staple line was inspected for hemostasis and was found to be hemostatic. The ports were then removed under direct vision and found to be hemostatic. The umbilical port was then reapproximated using 2-0 Vicryl in a figure-of-eight fashion. The skin was reapproximated using 4-0 Vicryl. Subcuticular closure, benzoin, Steri-Strips were then applied as well as Tegaderm. The sponge, needle, and instrument counts were reported correct at the end of the case x2. The patient was awakened from general anesthesia and taken to the recovery room in satisfactory condition.
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