GENERAL SURGERY MEDICAL TRANSCRIPTION SAMPLE REPORT
PREOPERATIVE DIAGNOSIS: Right internal carotid artery stenosis, 90%.
POSTOPERATIVE DIAGNOSIS: Right internal carotid artery stenosis, 90%.
OPERATION PERFORMED: Right carotid endarterectomy with Hemashield patch graft.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine position. After general anesthesia was given, the skin of the right neck was prepped with DuraPrep and draped in a sterile fashion. The right neck was explored through an incision along the anterior border of the sternocleidomastoid muscle.
An incision was made through the subcutaneous tissue, platysma divided, bleeders controlled with electrocautery. The fascial veins and lingual veins were divided and ligated with 2-0 black silk. The common carotid, internal and external carotid arteries, as well as the superior thyroid artery were isolated with vessel loops. The patient was heparinized, given 7000 units of heparin. Internal, external carotid arteries were clamped.
Arteriotomy made in the common carotid artery extending to the internal, endarterectomy of these vessels were performed. The arteriotomy was repaired with a Hemashield patch graft with a continuous 6-0 Prolene suture material. The clamps were released. Circulation established to the external and internal carotid artery. The patient was given 75 mg of protamine sulfate. The patient had diffuse bleeding to the suture line and a few interrupted sutures were placed to control the bleeding until this was under control.
The area was irrigated with antibiotic solution. The platysma was closed with continuous 2-0 Vicryl and the skin closed with subcuticular 4-0 Vicryl and a sterile dressing was applied. The patient tolerated the procedure well and was sent to recovery in stable condition.
