General Surgery Operative Sample Report #1
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chronic abdominal pain, probable adhesions.
POSTOPERATIVE DIAGNOSIS: Chronic abdominal pain, probable adhesions.
OPERATION PERFORMED: Diagnostic laparoscopy and lysis of adhesions.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old female with history of adhesions and chronic abdominal pain. She has undergone diagnostic laparoscopy by her gynecologist in the past with relief of these symptoms; however, she has had return of symptoms, especially in the left lower quadrant and the lower midline. We offered her conservative management versus laparoscopy, and she has consented for laparoscopy. Risks versus alternatives have been discussed with her, and she has consented for surgery.
DESCRIPTION OF OPERATION: The patient was brought to the OR and placed supine on the operating table. After undergoing anesthesia, her abdomen was prepped and draped in sterile fashion using DuraPrep. A 5 mm Optiview trocar was placed in the supraumbilical position and the abdomen was insufflated. Two right lower 5 mm trocars were placed, and the entire abdomen was explored. There were some adhesions to the sigmoid and her left ovary, which we were able to free up with scissors. There were also adhesions in the right paracolic gutter, which we took down. The operative site was hemostatic. Rest of bowel appeared normal, and there were no other issues. There was a small endometrioma in the peritoneum, which we cauterized. Mesh was placed in both sides where we lysed the adhesions to help prevent any further issues. Abdomen was desufflated and trocars were removed. The 4-0 Monocryl and Steri-Strips were applied. The patient was awakened and transferred to PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Pulmonary hypertension.
POSTOPERATIVE DIAGNOSIS: Pulmonary hypertension.
PROCEDURE PERFORMED: Right subclavian dual-lumen Hickman placement.
SURGEON: John Doe, MD
ANESTHESIA: MAC using 1% lidocaine.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old lady with pulmonary hypertension on continuous Flolan therapy. She has had a recent Hickman infection, which was removed and a PICC line placed. She has returned for Hickman placement. The risks, benefits, and alternatives have been discussed with the patient, and she has consented for surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR and placed supine on the operating table. After adequate anesthesia, the patient’s chest was prepped and draped in a sterile fashion with DuraPrep. The right subclavian venipuncture was performed. Guidewire was passed to the right heart. A dual-lumen Hickman was tunneled from an inferior stab incision, entered through a styloid, and passed with a guidewire, and the catheter was passed through the introducer sheath to the atriocaval junction. The catheter was accessed and flushed and aspirated well through both ports. It was secured to the skin at the site with 2-0 Prolene. The venipuncture site was closed using 4-0 Monocryl. Steri-Strips, sterile dressing, and Tegaderm were applied. The patient was awoken and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #3
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Dislodged PEG tube.
POSTOPERATIVE DIAGNOSIS: Dislodged PEG tube.
PROCEDURE PERFORMED: Laparotomy and reinsertion of G-tube.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old female with mental status changes status post a stroke. A PEG tube was placed; however, within 48 hours, she had inadvertently pulled it out. A G-tube was needed for nutrition, as well as concern for a gastric leak. We took her to the operating room for reinsertion.
DESCRIPTION OF PROCEDURE: The patient was brought into the OR and placed supine on the operating table. After undergoing sedation, the abdomen was prepped and draped in surgical fashion with DuraPrep. An upper vertical midline incision was made. Dissection was taken down to the fascia, and the peritoneum was entered. The stomach had dropped away from the abdominal wall. The gastrotomy was identified. A 20-French MIC tube was brought through the anterior abdominal wall. Two 2-0 silk purse-string sutures were placed around the previous PEG gastrotomy, and the new G-tube was inserted into that site. The two purse-strings were tied down. The stomach was resecured to the anterior abdominal wall with 2-0 silk stitches using approximately four of those. The fascia was closed using 0 PDS running, and 3-0 Vicryl and 4-0 Monocryl were used to close the skin. Steri-Strips, sterile dressing, and Tegaderm were applied. The patient was awoken and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #4
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Pancreatic cancer.
POSTOPERATIVE DIAGNOSIS: Pancreatic cancer.
PROCEDURE PERFORMED: Left subclavian venous Port-A-Cath.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: MAC using 1% lidocaine.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman with pancreatic cancer. He is scheduled to undergo chemotherapy. A Port-A-Cath has been elected. The risks, benefits, and alternatives have been discussed with him, and he has consented for surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating room table. After undergoing sedation, his left neck was prepped and draped in the usual sterile fashion using Dura-Prep.
A left subclavian venipuncture was performed and a guidewire passed into the right heart. A port pocket was fashioned on the chest wall, and the port was secured in the pocket with two 2-0 Prolenes. An introducer dilator was passed over the guidewire, and the catheter was passed through the introducer sheath to the atriocaval junction. The catheter was cut and attached to the port. Prolenes were then tied down. The port was accessed and flushed and aspirated well. The skin was closed using 3-0 Vicryl and 4-0 Monocryl. Steri-Strips, sterile dressing, and Tegaderm were applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
The skin was closed using 3-0 Vicryl and 4-0 Monocryl. Steri-Strips, sterile dressing, and Tegaderm were applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #5
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Incisional hernia.
POSTOPERATIVE DIAGNOSES:
1. Incisional hernia.
2. Umbilical hernia.
OPERATION PERFORMED: Repair of incisional and umbilical hernia with mesh.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old gentleman with a right paramedian incision, a small incisional defect. He also has a small umbilical hernia. We have recommended repair. Risks, benefits, and alternatives have been discussed with the patient, and he has consented for surgery.
DESCRIPTION OF OPERATION: The patient was brought to the OR and placed supine on the operating table. After undergoing the anesthesia, his abdomen was prepped and draped in surgical fashion with DuraPrep and Ioban. The right paramedian scar was excised. Dissection was taken down to the fascia, and there was a small defect in the anterior fascia. We worked away medially towards the umbilicus, and there was
The right paramedian scar was excised. Dissection was taken down to the fascia, and there was a small defect in the anterior fascia. We worked away medially towards the umbilicus, and there was umbilical hernia as well. The umbilicus was taken off the underlying hernia sac and the hernia was reduced. Both defects were closed with interrupted 0 Ethibonds. The whole area was reinforced with polypropylene mesh, which was tagged to the anterior fascia with interrupted 0 Ethibonds.
We copiously irrigated out the subcutaneous tissues. The 2-0 Vicryl was used to close the dead space, 3-0 Vicryls were used to close the subcutaneous tissue, and 4-0 Monocryls and Steri-Strips were used to closed the skin. The patient was awoken and transferred to PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #6
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Lymphoma.
POSTOPERATIVE DIAGNOSIS: Lymphoma.
PROCEDURE PERFORMED: Left subclavian PowerPort placement.
SURGEON: John Doe, MD
ANESTHESIA: MAC using 1% lidocaine.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female with lymphoma. She is undergoing chemotherapy. Port-A-Cath has been elected. We opted to place the PowerPort. Risks, benefits, and alternatives have been discussed, and she has consented for surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. After adequate sedation, the left neck and chest were prepped and draped in the sterile fashion with DuraPrep. The left subclavian venipuncture was performed. Guidewire passed into the right heart and confirmed under fluoroscopy. Port pocket was fashioned on the chest wall. Port was secured to the pocket with two 2-0 Prolenes. Introducers and dilators were passed over the guidewire, and the catheter was passed through the introducer sheath to the atriocaval junction. The catheter was cut and attached to the port. The port was placed in the pocket and Prolenes were tied down. The port was accessed and flushed and aspirated well. The entire course of the port was observed under fluoroscopy showing good curvature and no kinks. The 3-0 Vicryls and 4-0 Monocryls were used to close the skin. Steri-Strips, sterile dressing, and Tegaderm were applied. The patient was awoken and transferred to PACU in satisfactory condition. Chest x-ray was ordered and will be reviewed prior to discharge.
General Surgery Operative Sample Report #7
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Breast mass.
POSTOPERATIVE DIAGNOSIS: Breast mass.
PROCEDURE PERFORMED: Excision of right breast mass.
SURGEON: John Doe, MD
ANESTHESIA: Local.
COMPLICATIONS: None.
SPECIMENS REMOVED: None.
INDICATION FOR PROCEDURE: This (XX)-year-old woman presented with palpable right breast mass. It was unidentifiable on mammogram. It is lateral and we doubt it will be picked up with imaging. The patient has a strong desire to have it excised and we recommended we proceed. The risks, benefits, and alternatives were discussed with the patient and she consented to surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR and placed supine on the operating table. The right breast was prepped with DuraPrep. After identifying the lesion, the area was infiltrated with 1% lidocaine. A small incision was made and dissection taken down through the breast tissue. The nodule was identified and removed completely. It was a thoroughly benign-looking nodule and was sent for final pathology. The 4-0 Monocryl and Steri-Strips were used to close the skin. Sterile dressing and Tegaderm were applied. The patient was awoken and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #8
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Biliary dyskinesia.
POSTOPERATIVE DIAGNOSIS: Biliary dyskinesia.
OPERATION PERFORMED: Laparoscopic cholecystectomy with intraoperative cholangiogram.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS REMOVED: Gallbladder.
INDICATION FOR OPERATION: This (XX)-year-old gentleman was admitted to the hospital with right upper quadrant pain. HIDA scan showed delayed filling of the gallbladder and nonemptying with an ejection fraction of 0%. We recommended based on this that he undergo cholecystectomy. The risks, benefits, and alternatives have been discussed with the patient and he consented for surgery.
DESCRIPTION OF OPERATION: The patient was brought to the OR and placed supine on the operating table. After undergoing anesthesia, his abdomen was prepped and draped in sterile fashion with DuraPrep. A 5 mm trocar was placed in the supraumbilical position. A 10 mm was placed in the subxiphoid and two right lateral 5 mm trocars were placed. The fundus of the gallbladder was grasped and retracted over the liver. The infundibulum was retracted inferolaterally. The cystic duct was dissected free. A clip was placed on the neck of the gallbladder. Ductotomy was performed. Cholangiogram catheter was passed in the cystic duct and cholangiogram was shot showing normal biliary anatomy. Two clips were placed distally and the cystic duct was transected. The cystic artery was clipped twice proximally, once distal and divided. The gallbladder was removed from the liver bed with the Bovie spatula and removed through the subxiphoid trocar site. The liver bed was hemostatic. We irrigated and suctioned out the irrigant. The working trocar was removed and then finally the camera trocar. The abdomen was desufflated. The 4-0 Monocryl and Steri-Strips were used for the skin. The patient was awoken and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #9
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left arm lipoma.
2. Left flank lipoma.
POSTOPERATIVE DIAGNOSES:
1. Left arm lipoma.
2. Left flank lipoma.
PROCEDURE PERFORMED: Excision of both lipomas.
SURGEON: John Doe, MD
ANESTHESIA: MAC using 1% lidocaine.
COMPLICATIONS: None.
SPECIMENS: Lipoma x2.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old gentleman with painful lipomas of the left flank and left arm. We have recommended excision. Risks, benefits, and alternatives were discussed with him and he consents for surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR and placed supine on the operating table. After undergoing sedation, the left arm was prepped with DuraPrep and infiltrated with 1% lidocaine. An incision was made over the lipoma and it was shelled out. The 4-0 Monocryl and Steri-Strips were used to close that wound. Next, the patient was rolled in the right lateral decubitus position. The left flank lipoma was prepped with DuraPrep. An incision was made over the lesion. Dissection was taken down to the subcutaneous tissue and it was shelled out. The 3-0 Vicryl and 4-0 Monocryl were used to close the skin. Steri-Strips, sterile dressing, and Tegaderm were applied. The patient was awoken and transferred to PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Operative Sample Report #10
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Preop for preparation for stem cell transplantation.
POSTOPERATIVE DIAGNOSIS: Preop for preparation for stem cell transplantation.
PROCEDURE PERFORMED: Left subclavian Neostar.
SURGEON: John Doe, MD
ANESTHESIA: MAC.
COMPLICATIONS: None.
SPECIMENS: None.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR and placed supine on the operating table. After undergoing sedation, the left neck and chest were prepped and draped in standard sterile fashion with DuraPrep. Left subclavian venipuncture was performed. A guidewire was passed to the right heart and confirmed under fluoroscopy. Neostar was tunneled up from an inferior stab incision. It was cut to length just inside the right atrium. Introducer dilator was passed over the guidewire, and the catheter was passed through the introducer sheath through the atriocaval junction. The sheath was removed. Catheter was accessed. It flushed and aspirated well. It was secured to the skin exit site with 2-0 Prolene. Monocryl closed the venipuncture site. Steri-Strips were applied. The patient was awoken and transferred to PACU in satisfactory condition. The patient tolerated the procedure well.
