DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Menorrhagia.
2. Dysfunctional uterine bleeding.
3. Small leiomyomata uteri.
POSTOPERATIVE DIAGNOSES:
1. Small endometrial polyp.
2. Dysfunctional uterine bleeding.
OPERATION PERFORMED:
1. Diagnostic hysteroscopy.
2. Diagnostic dilation and curettage of uterus.
3. Excision of endometrial polyp.
SURGEON: John Doe, MD
ANESTHESIA: General.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gravida 3, para 1, AB 2 female, who has a long history of menorrhagia and dysfunctional uterine bleeding. The patient has had several ultrasound reports, the most recent one revealed a small fundal myoma. Other ultrasound reports have suggested a possible small submucous myoma. Because of continued menorrhagia and dysfunctional uterine bleeding episodes, the patient is being admitted for diagnostic surgery.
DESCRIPTION OF PROCEDURE: Under excellent general anesthesia, the patient was prepped and draped in the modified dorsal lithotomy position. Pelvic exam revealed the uterus to be in the mid position and slightly enlarged and symmetric. Examination of both adnexa revealed no masses. A weighted speculum was introduced into the vaginal vault. The anterior lip of the cervix was grasped with a single tooth tenaculum. The cervical os was progressively dilated. The diagnostic hysteroscope was then placed through the cervical canal. After extensive irrigation, the endometrial cavity was clearly visualized. Both tubal ostia were visualized and appeared to be normal. At the top of the endometrial cavity, in the fundal region, was a small endometrial polyp, about 3 x 3 mm in dimension. Otherwise, there were no myomas visualized. At this time, the uterine cavity was then thoroughly curetted. Reinspection of the entire cavity revealed the polyp to be still in place at the dome of the fundus. At this time, small grasping forceps was placed through the hysteroscopic channel and the polyp was grasped and twisted off its base and sent as a separate specimen. The patient tolerated the procedure well. Total blood loss from the surgery was less than 10 mL. She returned to the recovery room in excellent condition with sponge and instrument counts correct.
Gynecology Medical Transcription Operative Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Menometrorrhagia secondary to submucosal fibroid.
POSTOPERATIVE DIAGNOSIS: Menometrorrhagia secondary to submucosal fibroid.
OPERATION PERFORMED: Hysteroscopic myomectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 25 mL.
ANTIBIOTICS: Prophylactic antibiotic with cefoxitin 2 g given intravenously within 1 hour of the surgery.
DESCRIPTION OF PROCEDURE: After general anesthesia was given, the patient was prepped and draped in the usual manner in a dorsal lithotomy position. Pelvic examination was done and found the uterus to be slightly irregular and enlarged. There were no gross adnexal masses that were palpated. At the time of prep, one laminaria and gauze was removed. A weighted speculum was then placed into the vagina. The anterior cervix was then grasped with a single tooth tenaculum. The resectoscope was easily inserted into the endometrial cavity. Both ostia were visualized and found to be normal. Noted was submucosal fibroid that was protruding slightly into the endometrial cavity. Then, using resectoscope, the fibroid was then gradually resected. Tissue was everted within the endometrial cavity. The procedure was completed after several passes and most of the fibroid had been removed. Specimen was sent to pathology. After this was done, the Overstreet polyp forceps was used to remove the remainder of the submucosal fibroid. After this was completed, the area was then inspected and bleeding was found to be of minimal amount. The resectoscope as well as single tooth tenaculum were removed. The patient was repositioned in supine position and taken to the recovery room in satisfactory condition.
Gynecology Medical Transcription Operative Sample Report #3
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Pelvic mass.
POSTOPERATIVE DIAGNOSIS: Left ovarian cyst.
OPERATION PERFORMED: Left salpingo-oophorectomy via laparoscopy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 10 mL.
DESCRIPTION OF PROCEDURE: Under adequate general anesthesia, the patient was prepped and draped in dorsal lithotomy position. A single blade weighted speculum was placed into the vagina. The anterior lip of the cervix was grasped with the single tooth tenaculum. Cohen cannula placed. There was some difficulty in catheterizing her bladder. Urethra was somewhat stenotic and would not accept the 14 French catheter; therefore, a 10 French catheter was placed. Attention was then turned to the abdomen. A small umbilical incision was made and immediately the abdomen was entered. The second trocar sites were placed at a 5 mm site on the left and a 10 mm site on the right in the area of the previous incision. The uterus was normal. The right ovary was normal, although somewhat adherent to the posterior left side of the uterus. There was a large multiloculated ovarian mass in the cul-de-sac consistent with ultrasound report. This was somewhat large, approximately 8 cm in diameter. This was somewhat adherent to the sidewall. The infundibulopelvic ligament was cauterized for a distance of about 1.5 cm and then cut. Fallopian tube was cauterized and cut near the cornual region and the utero-ovarian ligament was cauterized and cut. At that point, there was noted the adhesions of the ovary to the posterior cul-de-sac and these filmy adhesions were carefully cauterized and cut taking care to stay on the ovary side of the adhesions, close to the ovary, and not into the sidewall. Good hemostasis noted throughout. The ovary was freed from its adhesion, placed into the Endopouch bag. The ovary needed to be taken in piecemeal, as it was quite enlarged and would not easily fit through the 1 cm incision. This was taken out in piecemeal with Allis clamps and there was noted to be a large amount of old chocolate-type cyst material within this cyst. Taking the ovary out piecemeal, we were able to take the ovary out in several pieces and sent to the lab. The abdomen was carefully irrigated. Good hemostasis noted throughout. Second puncture sites were taken out under direct visualization. The umbilical and right lower quadrant port fascia was closed with interrupted suture of 2-0 Vicryl. Skin closed with 4-0 Vicryl, subcuticular stitch, at all port sites. Good hemostasis noted. Steri-Strips placed. The patient was taken to the recovery room in stable condition.
