OB-GYN Medical Transcription Operative Sample Report #1
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Complex left adnexal mass.
POSTOPERATIVE DIAGNOSIS: Left ovarian dermoid cyst.
OPERATION PERFORMED: Laparoscopic left partial salpingo-oophorectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ANESTHESIOLOGIST: Jean Doe, MD
IV FLUIDS: Crystalloid.
ESTIMATED BLOOD LOSS: Less than 5 mL for this portion of the procedure.
DESCRIPTION OF PROCEDURE: After appropriate informed consent was obtained, the patient was taken to the operating suite, given general endotracheal anesthesia, and then prepped and draped in the usual sterile fashion in the dorsal supine position with a Foley catheter in place. I arrived after the gastric portion of the procedure had been performed by Dr. Doe and found there were 3 ports in place, specifically a 10 mm umbilical port, a 10 mm right lower quadrant port, and a 5 mm left mid quadrant port that had been removed.
I placed a 5 mm left lower quadrant port through a stab wound under direct visualization after carbon dioxide was insufflated. The ovary was grasped carefully. The Harmonic scalpel was used to circumscribe the ovary away from the hilum and then the capsule was incised with scissors, and traction and countertraction were used along with hydrodissection in order to peel the ovarian cyst away from the normal ovarian tissue. There was excellent hemostasis throughout this portion of the procedure.
A small puncture wound occurred about three-fourths of the way through the dissection, and a few droplets of fat escaped, but other than that, there was no evidence of any extrusion of any material.
The cyst was placed in a bag and then removed through the right lower quadrant port piecemeal without contaminating the peritoneal cavity.
The port was replaced. Carbon dioxide was insufflated, and a portion of the ovary was excised to restore normal anatomy. The ovary was then grasped, and 2 separate interrupted #3-0 Vicryl sutures were placed using laparoscopic technique with external knot pusher. There was excellent hemostasis.
Therefore, copious irrigation was undertaken with about 2000 mL of fluid, and all the irrigant was removed. There was no evidence of any contamination with fat or other tissue. The sidewalls were clean and the cul-de-sac was clean. Therefore, Interceed was placed around the hemostatic ovary, tacked down with saline, and then the instruments were removed under direct visualization. The fascial incisions were sewn with #2-0 Vicryl for the right lower quadrant and #2-0 PDS for the umbilical incision, and then staples were used to close the skin edges. Dressings were applied, and the patient was taken from the operating suite after extubation with instrument and sponge counts correct, having tolerated the procedure without complications.
OB-GYN Medical Transcription Operative Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
OPERATION PERFORMED: Hysteroscopy, uterine curettage, and endometrial polyp excision.
OPERATIVE FINDINGS: Normal size anteverted uterus. No adnexal masses. Uterine sound 6 cm with a very small polyp at the fundus of the endometrium. Normal tubal ostia; otherwise, very minimal endometrial tissue.
COMPLICATIONS: None.
Distention media was used glycine. Glycine deficit was zero at the end of the procedure. There were no complications.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the dorsal supine position. After induction of general anesthesia, the patient was placed in the dorsal lithotomy position, and the perineum was prepped and draped in the usual sterile fashion. Examination under anesthesia revealed findings described above. A speculum was inserted into the vagina. A sharp-tooth tenaculum was used to grasp the anterior lip of the cervix. The endocervical canal was then dilated after sounding the uterus to 6 cm. It was easily dilated to a #20 Hanks dilatation. A rigid hysteroscope was then inserted, which revealed very thinned out endometrial echo with a very small endometrial fluffy polyp at the fundus of the uterus measuring approximately 2 mm. We then removed the scope, used the polyp forceps to remove the polyp and curetted the endometrial cavity removing a very minimal amount of tissue. The scope was inserted at the end of the procedure, which revealed that the polyp had been removed. Adequate hemostasis was noted. All instruments were removed from the vagina. Minimal bleeding from the tenaculum site was controlled with silver nitrate and pressure. She tolerated the procedure well with no complications and was sent to the recovery room in satisfactory condition.
