Medical Transcription OB/GYN Operative Sample Reports for Medical Transcriptionists:
OPERATION PERFORMED: Total vaginal hysterectomy and anterior and posterior repair.
OPERATION IN DETAIL: The patient was taken to the operating room. After general anesthesia was achieved, she was then placed in the dorsal lithotomy position. Exam under anesthesia revealed a second-degree uterine prolapse. At this point, the patient was prepped and draped in the usual manner. A single-tooth tenaculum was then placed on the cervix for traction. A posterior colpotomy incision was then made. The peritoneum was then sutured to the posterior vaginal mucosa. The anterior mucosa was then sharply dissected away from the cervix. The uterosacral ligaments were then isolated, clamped and cut. The 0 Vicryl was used for all pedicles. Cardinal ligaments were isolated, clamped and cut. Progressive pedicles were then formed, going up through the extended uterine isthmus. At this point, an anterior colpotomy incision was then made. The anterior and posterior peritoneum were then included in all sutures. The vessels were isolated, clamped and doubly ligated. Upper pedicle was then clamped and cut and the specimen was then removed. Angled sutures at this point were put in bilaterally. This consisted of the lateral angle of the vaginal mucosa, the upper peritoneum, the upper pedicle, the cardinal uterosacral ligaments, and posterior peritoneum. The bladder was then catheterized and drained with a Foley. Using 0 silk, a pursestring suture was then placed in the cul-de-sac posterior to prevent an enterocele formation. The peritoneum was then closed anterior to posterior. Two Heaney clamps were placed across the anterior vaginal mucosa. The bladder underlying was then dissected away. This was a sharp dissection. Two sutures were then put in, Heaney style, to re-form the uterovesical angle. Excessive vaginal mucosa was then trimmed. The anterior vaginal mucosa was then closed, as was the cuff. Angled sutures were then tied. The hymenal ring was then identified and two Kocher clamps were placed on top. A triangular tissue was then removed. The posterior vaginal mucosa was then dissected away from the underlying rectal mucosa. The levators were then brought in the midline to close the defect. The posterior peritoneal mucosa was then trimmed away and the posterior mucosa was closed with the perineum being rebuilt. Packing was put in. The patient was then placed supine, awakened, and taken to the recovery room in excellent condition.
OPERATION PERFORMED: Examination under anesthesia, right salpingo-oophorectomy, total abdominal hysterectomy.
OPERATION IN DETAIL: The patient was taken to the operating room and given general anesthesia. She was then placed in the frog-leg position. Examination under anesthesia revealed a large right ovarian cyst. At this point, the patient was placed supine after she had been prepped and draped in the usual manner. A low transverse incision was then made. The scalpel was changed and the incision was carried down through the underlying fascia. The fascia was opened transversely, exposing underlying rectus muscles, which were opened in the midline. The peritoneal cavity was then entered. Fluids were then collected in the form of pelvic washings. The incision was then extended. A Balfour retractor was then used. The cyst was then delivered intact through the abdominal incision. A clamp was placed across the stalk and the specimen was removed and sent to pathology. At this point, the hysterectomy was performed. Both round ligaments were identified, clamped and cut. A bladder flap was then made. The LigaSure was then used and pedicles were formed down to the uterine vessels. The uterine vessels were isolated, clamped and cut bilaterally after the bladder had been pushed out of the way. The cardinal and uterosacral ligaments were isolated, clamped and cut. The vagina was then entered. The specimen was then removed. The vagina was then closed using several interrupted vaginal sutures. All packing was then removed. The peritoneum was then closed. The muscle layers were reapproximated and closed. The fascia was then closed in two layers with internal and external obliques being closed separately. Several subcutaneous stitches were put in. The skin was then closed. The patient was then taken to the recovery room in excellent condition.
PROCEDURE PERFORMED: Cold knife conization of the cervix.
PROCEDURE IN DETAIL: The patient was taken to the operating room, and under adequate general anesthesia, the patient was prepped and draped in the dorsal lithotomy position for a vaginal procedure. A red rubber catheter was used to drain the patient's bladder. Two vaginal retractors were placed in the vagina to visualize the cervix, which was painted with Lugol solution. Stitches of #1 Vicryl were placed at the 3 o'clock and 9 o'clock positions for traction. The cervical stroma was then infiltrated with approximately 15 mL of 1% lidocaine with epinephrine at a 1:200,000 dilution. An 11 blade scalpel was used to remove the cone specimens. A suction Bovie was then used to cauterize the base of the surgical site, which was easily made hemostatic. Sturmdorf stitches were placed at the 12 o'clock and 6 o'clock position to help the cervix fold in on itself for hemostasis. The 3 o'clock and 9 o'clock positions were also tied together. There was no evidence of active bleeding at the end of the procedure. Sponge, instrument, and needle counts were all correct. The patient tolerated the procedure well and was taken to the recovery room.
OPERATION PERFORMED: Total abdominal hysterectomy and right salpingo-oophorectomy.
OPERATION IN DETAIL: The patient was taken to the operating room, and under adequate general anesthesia, Foley catheter was in place. The patient was prepped and draped in the supine position for the abdominal procedure. A low transverse skin incision was made with a knife approximately one fingerbreadth above the pubic symphysis through the patient's previous skin scar. The subcutaneous tissue was incised sharply with Bovie to the level of the fascia, which was nicked in the midline. The fascial incision was extended laterally with Mayo scissors. The underlying rectus muscles were bluntly and sharply dissected free. Rectus muscles were separated in the midline, and the underlying parietal peritoneum was entered bluntly. Peritoneal incision was extended superiorly and inferiorly with Metzenbaum scissors. A self-retaining O'Connor-O'Sullivan retractor was placed. A bladder blade was placed. The bowel and omentum were packed cephalad with moist laparotomy sponges and an additional retractor was placed. The fundus of the uterus was grasped with a Lahey clamp. The pelvic contents were inspected. The left fallopian tube and ovary were surgically absent. There was a minimal amount of old endometriosis present in the posterior cul-de-sac. Otherwise, there were no adhesions or lesions that were obvious. The right round ligament was doubly clamped with Kelly clamps, transected with Metzenbaum scissors. Retroperitoneal space was dissected to identify the ureter. The round ligament was suture ligated with 0 Vicryl suture. A defect was made in the broad ligament through which a Heaney clamp could be passed to encompass the infundibulopelvic ligament, which was then transected and suture ligated with 0 Vicryl suture followed by 0 Vicryl free ties. Same procedure was performed on the contralateral side to open up the broad ligament and help develop the bladder flap. The bladder flap was then pushed caudally. Uterine vasculature was skeletonized, clamped, transected with a knife, and suture ligated with 0 Vicryl suture. Sequential bites were taken through the cardinal ligaments straight down, transecting the pedicles with knife and suture ligated with 0 Vicryl suture. At the level of the external cervical os, two Heaney clamps were placed in opposition. Pedicles were transected with Mayo scissors, and the cervix was then circumcised off the vagina with Jorgenson scissors. Angled stitches were placed using 0 Vicryl suture in a Heaney stitch fashion. The remainder of the cuff was closed using 0 Vicryl suture in an interrupted figure-of-eight fashion. There was no evidence of active bleeding from any of the pedicles. The pelvis was irrigated with a solution of saline and Kantrex. Again, the pedicles were inspected and found to be hemostatic. A piece of Interceed was placed in the pelvic floor overlying the vaginal cuff to help prevent the formation of scar tissue to the cuff. Self-retaining O'Connor O'Sullivan retractor was removed as were the laparotomy sponges. The parietal peritoneum was closed using 2-0 Vicryl suture in running fashion. Subfascial space was inspected and found to be hemostatic. The fascia was then closed in a running fashion with 0 Vicryl suture x2 meeting in the midline. The subcutaneous tissue was reapproximated using 3-0 Vicryl suture in interrupted fashion and the skin was closed in a subcuticular fashion using 4-0 Monocryl. At the end of the procedure, sponge, instrument, and needle counts were all correct. The patient tolerated the procedure well and was taken to the recovery room.
OPERATION PERFORMED: Laparoscopic bilateral tubal ligation with electrofulguration.
OPERATION IN DETAIL: The patient was taken to the operating room, and under adequate general anesthesia, the patient was prepped and draped in the dorsal lithotomy position for vaginal/abdominal procedures. A red rubber catheter was used to drain the patient's bladder. Two vaginal retractors were placed in the vagina to visualize the cervix, which was grasped on the anterior cervical lip with a long Allis clamp. A Cohen uterine manipulator was inserted through the endocervix, attached to the long Allis clamp. Two vaginal retractors were withdrawn and the focus was then turned towards the abdominal portion of the procedure. A subumbilical skin incision was made with a knife. The abdomen was tented up and an 11 mm bladeless trocar was inserted under direct visualization with the laparoscope. Carbon dioxide gas was used to create a pneumoperitoneum. The bowel and omentum underlying the insertion site were inspected and found to be free of injury. The pelvic contents were inspected, which grossly appeared normal. The right fallopian tube was grasped and traced to its fimbriated end to assure its identity. It was grasped at the mid portion of the tube with the bipolar Kleppinger forceps, elevated, pulled medially away from any adjacent structure and electrofulgurated until no tissue resistance was met. Adjacent areas both proximal and distal to the initial fulguration site were also fulgurated until no tissue resistance was met. The same procedure was performed on the contralateral tube. Pictures were taken both before and after fulguration. Carbon dioxide gas was allowed to escape. The trocar was removed. The skin incision was closed using 4-0 Monocryl in subcuticular fashion. The Allis clamp and Cohen uterine manipulator were removed from the patient's cervix, which was found to be hemostatic. At the end of the procedure, sponge, instrument and needle counts were all correct. The patient tolerated the procedure well.
OPERATION PERFORMED: Operative laparoscopy and chromopertubation of fallopian tubes.
OPERATION IN DETAIL: The patient was taken to the operating room, and under adequate general anesthesia, the patient was prepped and draped in the dorsal lithotomy position for vaginal and abdominal procedures. A Foley catheter was placed. Two vaginal retractors were placed in the vagina to visualize the cervix, which was grasped at the anterior cervical lip with a long Allis clamp. The uterine cavity was then sounded to 7 cm. A HUMI uterine manipulator was then set to the appropriate depth and inserted. The balloon was filled. The Allis clamp was then removed from the cervix and the focus was then turned towards the abdominal portion of the procedure. A subumbilical skin incision was made with a knife. The abdomen was tented up and an 11 mm bladeless trocar was inserted under direct visualization with the laparoscope. Carbon dioxide gas was used to create pneumoperitoneum. The bowel and omentum underlying the insertion site were inspected and found to be free of injury. A distal trocar site was placed in the midline approximately two fingerbreadths above the pubic symphysis by scoring the skin with a knife and inserting a 5 mm trocar under direct visualization. Pelvic contents were then inspected. The uterus was retroverted and retroflexed, however, showed no evidence of subserosal lesions or adhesions. The anterior sac as well as the round ligaments were inspected and found to be free of lesion or adhesion. Both orifices, tubes, and ovaries grossly appeared normal. There were no lesions seen in either ovarian fossae. Posterior cul-de-sac and the uterosacral ligaments were free of lesion and adhesion. The patient's appendix was surgically absent. There were some adhesions in this area involving the small bowel to the pelvic sidewall; however, there was no evidence of adhesion involving the pelvis. A solution of normal saline and indigo carmine was prepared and instilled through the HUMI. There was rapid spill-through the left fallopian tube; however, the right fallopian tube had a distal occlusion. A duckbill grasper was used to create a small kink in the left fallopian tube, and with increasing the pressure, the dye then seemed to be spilling out of the right fallopian tube as well. The pelvis was then irrigated with saline. There was no evidence of active bleeding. Carbon dioxide gas was allowed to escape. The trocars were removed. The skin incisions were closed using 4-0 Monocryl in a subcuticular fashion. The Foley was removed after noting clear urine in the bag. The HUMI was removed from the patient's cervix, which was found to be hemostatic. At the end of the procedure, sponge, instrument and needle counts were all correct. The patient tolerated the procedure well and sent to the recovery room.
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