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Showing posts from November, 2011

Removal of deep implant (OP Report Sample)

PREOPERATIVE DIAGNOSIS: Symptomatic retained hardware, status post open ankle fracture dislocation right ankle.

POSTOPERATIVE DIAGNOSIS: Symptomatic retained hardware, status post open ankle fracture dislocation right ankle.

OPERATIONS PERFORMED: Removal of deep implant. Incisions right ankle.

OPERATION: Patient was taken to the operating room, and after induction of general anesthesia with laryngeal mask intubation, the right lower extremity was prepped and draped in the usual fashion.  A tourniquet was applied prior to prepping and draping for total tourniquet time at 300 mmHg; please refer to the nurse's notes.  A safety time-out was performed, and the patient was properly identified.  After exsanguination, tourniquet was elevated. The previous lateral approach was used.  Skin and subcutaneous tissues were divided.  We elevated peroneal musculature posteriorly off of the fibula exposing the fibular plate.  We removed the screws without difficulty and the plate without difficulty, …

Repair of total anomalous pulmonary venous connection (OP Report Sample)

PREOPERATIVE DIAGNOSES: Total anomalous pulmonary venous connection, atrial septal defect, patent ductus arteriosus.

POSTOPERATIVE DIAGNOSES: Total anomalous pulmonary venous connection, atrial septal defect, patent ductus arteriosus plus the total anomalous pulmonary venous connection was of the mixed type with the left upper and left lower veins and the right lower veins draining to a common vein, which drained directly to the junction of the superior vena cava and the right atrium and the right upper and right middle veins drained directly to the superior vena cava.

OPERATION PERFORMED: Repair of total anomalous pulmonary venous connection with connection of the common vein to the back of the left atrium, suture closure of the atrial septal defect, and ligation of the patent ductus arteriosus.  The right upper and middle lobes veins were left draining to the superior vena cava as they were too small to transfer.

OPERATION: The patient was brought to the operating suite.  The patient w…

Umbilical herniorrhaphy with dual mesh repair (OP Report Sample)

PREOPERATIVE DIAGNOSIS:  Reducible umbilical hernia.

POSTOPERATIVE DIAGNOSIS:  Reducible umbilical hernia.

OPERATION PERFORMED:  Umbilical herniorrhaphy with dual mesh repair.

OPERATION:  Patient was brought to the operating room, placed in the spine position.  After induction of general anesthesia, the abdomen was prepped and draped in a sterile manner.  A curvilinear incision was made below the umbilicus and carried down to the fascia, at which point the hernia was exposed and excess sac was removed.  The hernia contents were reduced within the peritoneal cavity (preperitoneal fat) and we proceeded to place a piece of dual mesh cut to the appropriate size in an underlay fashion being held in place with multiple interrupted Prolene sutures.  The fascia was closed over the dual mesh with PDS suture and the skin was closed with running subcuticular Monocryl suture.  The patient tolerated the procedure without incident, was extubated and taken to the recovery room in good condition.

Laparoscopic Appendectomy

PREOPERATIVE DIAGNOSIS: Acute appendicitis.

POSTOPERATIVE DIAGNOSIS: Acute appendicitis.

OPERATION PERFORMED: Laparoscopic appendectomy.

FINDINGS:  Minimally dilated appendix with adhesions. Small right ovarian cyst.

OPERATION:  The patient was placed in supine position on the operating table.  The patient was placed under general endotracheal anesthesia.  A Foley catheter was placed in her bladder and an orogastric tube was passed.  Her lower extremities were placed in SCDs.  Her abdomen was prepared with chlorhexidine.  The patient was draped in standard sterile fashion.  Preoperative time-out was performed.  The patient received preoperative antibiotics, and again her lower extremities were placed in SCDs.

We began the operation by infiltrating the superior aspect of her umbilicus with local anesthetic consisting of 4% Marcaine with epinephrine.  Small incision was then made with a #11 blade.  Penetrating towel clips were placed in this incision and the umbilicus and the abdominal wall…

Open reduction and internal fixation or open treatment of bilateral mandibular fractures (OP Report Sample)

PREOPERATIVE DIAGNOSES:Left mandibular angle fracture.  Right parasymphyseal fracture.

POSTOPERATIVE DIAGNOSES: Left mandibular angle fracture.  Right parasymphyseal fracture.

OPERATION PERFORMED: Open reduction and internal fixation or open treatment of bilateral mandibular fractures including left angle and right parasymphyseal using multiple techniques, internal hardware fixation, and placement interdental fixation.

OPERATION: The patient brought to the operating room, draped, and prepped in routine manner.  The appropriate consents and time-outs were performed.  General anesthesia was performed by the Department of Anesthesia using a nasotracheal intubation.  At the beginning of the operation, the patient placement of IMF screws and the placement of the intermaxillary arch bars.  IMF screws placed on the maxilla and a lower arch bar was placed initially just the left half of the arch bar was fixated.  After this was performed, patient underwent exposure of the fractures through a rig…

Left thyroid lobectomy and isthmusectomy (OP Report Sample)

PREOPERATIVE DIAGNOSIS: Left thyroid follicular neoplasm.POSTOPERATIVE DIAGNOSIS: Left thyroid follicular neoplasm.OPERATION PERFORMED: Left thyroid lobectomy and isthmusectomy with intraoperative nerve monitoring and left cervical lymph node biopsy.
OPERATION: The patient was identified in the preoperative holding area and informed consent was assured.  The patient's left side was marked.  The patient was transported to the operating room and placed supine on the operating room table.  Bilateral lower extremity sequential compression devices were placed.  A dose of IV antibiotics was administered.  After successful induction of general endotracheal anesthesia, utilizing an endotracheal tube fitted with a nerve integrity monitoring system, the patient's arms were tucked.  All pressure points were padded.  A roll was placed behind her shoulders.  She was positioned in the semi-Fowler position.  A transverse incision was made in the line of a skin crease 2 fingerbreadths cephalad…

Open reduction, right intra-articular distal radius fracture -OP Report

PREOPERATIVE DIAGNOSIS: Right intra-articular distal radius fracture.

POSTOPERATIVE DIAGNOSIS: Right intra-articular distal radius fracture.

OPERATION PERFORMED: Open reduction, right intra-articular distal radius fracture, greater than or equal to 3 fragments.

ANESTHESIA: Is general.

BLOOD LOSS: Minimal.

COMPLICATIONS: None.

SPECIMENS: None.

FINDINGS:
Comminuted intra-articular distal radius fracture following a volar plating. The DRUJ was restored to acceptable stability and the fracture was restored to acceptable alignment.

INDICATIONS:

OPERATION:
Patient was met preoperatively, and this operative site marked by the operative team. Patient was then brought back to the operating room, transferred to the operating room table. SCDs were placed on her bilateral lower extremities. IV Ancef was given preoperatively. General anesthesia was then induced by the anesthesia team. A well-padded tourniquet was placed about her right upper extremity. Her right arm was pre-cleaned with ch…

Laparoscopic supracervical hysterectomy, bilateral salpingectomy, excision of peritoneal endometriosis -OP Report

PREOPERATIVE DIAGNOSIS: Endometriosis.

POSTOPERATIVE DIAGNOSIS: Endometriosis.

OPERATION PERFORMED: Laparoscopic supracervical hysterectomy, bilateral salpingectomy, excision of peritoneal endometriosis.

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

EBL: Minimal.

PATHOLOGY: Morcellated uterus, right and left fallopian tubes, pelvic peritoneum endometriosis.

FINDINGS:
Patient had about a 10-week size uterus, normal ovaries. She had bilateral tubal cysts. She had a nodule of endometriosis on her left pelvic sidewall overlying the ureter.

OPERATION:
After informed consent was reviewed with the patient, she was taken to the operating room with an IV running. General anesthesia was obtained without difficulty and she was prepped and draped in a modified lithotomy position in the Yellofin stirrups, her hands were tucked at her side, fingers safety padded and checked and her bladder was drained via transurethral Foley catheter.

Attention was turned to her umbilicus where an 11 mm…

Laparoscopic repair of bilateral inguinal hernias - OP Report

PREOPERATIVE DIAGNOSIS: Bilateral inguinal hernias.

POSTOPERATIVE DIAGNOSIS: Bilateral inguinal hernias.

OPERATION PERFORMED: Laparoscopic repair of bilateral inguinal hernias.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

ANESTHESIA: General.

SPECIMEN SENT: None.

OPERATIVE FINDINGS: There was a large hernia on the right side, indirect in nature, with a fairly substantial lipoma of the cord and properitoneal fat within the internal ring as well as a fairly scarred in hernia sac. On the right side, there was a patulous ring with properitoneal fat sitting unreduced within the internal ring and minimal sac exiting through the internal ring.

OPERATION: The patient was brought to the operating room, placed supine on the operating room table. General anesthesia was induced. A Foley catheter was inserted aseptically. The abdomen was prepped and draped sterilely below the umbilicus. Just below the umbilicus, a small midline incision was carried down through skin and subcut…

Robotic-assisted laparoscopic ureterolithotomy OP Report

PREOPERATIVE DIAGNOSES: 2 cm left proximal ureteral stone, 6 mm left lower pole renal stone.

POSTOPERATIVE DIAGNOSES: 2 cm left proximal ureteral stone, 6 mm left lower pole renal stone.

OPERATION PERFORMED: Robotic-assisted laparoscopic ureterolithotomy, intraoperative ureteroscopy with basketing of renal stone.

ANESTHESIA: General endotracheal.

FLUIDS: 2000 mL of crystalloid.

ESTIMATED BLOOD LOSS: 50 mL.

URINE OUTPUT: Not measurable.

COMPLICATIONS: None.

SPECIMENS: Stone sent for metabolic evaluation.

DRAINS:
• 16-French urethral catheter.
• 15-French round Blake drain.

DISPOSITION: Patient was taken to the recovery room in stable condition.

OPERATION:
Patient was brought to the operating room. The patient was identified by myself. The patient was intubated in the supine position. The patient was then placed in the left flank up position. The patient was prepped and draped in the standard sterile fashion. A surgical time-out was performed. The films were reviewed. A urethral c…

ORIF of distal tibia plafond intra-articular fracture OP Report

PREOPERATIVE DIAGNOSIS: Displaced left ankle distal tibial plafond fracture, intra-articular.

POSTOPERATIVE DIAGNOSIS: Displaced left ankle distal tibial plafond fracture, intra-articular.

OPERATION PERFORMED: ORIF of distal tibia plafond intra-articular fracture.

ANESTHESIA: General.

OPERATION:
Patient taken to the main operating theatre with anesthesia general. Ancef was given. A time-out was done. Sterile prep and drape was utilized. The tourniquet was set at 250 on the left leg and a bump was placed under the left hip. After elevation, exsanguination, the tourniquet was set, sterile prep and drape was done and fluoro imager was used to guide the skin incision, and an anterior 1-inch incision was made over the distal tibia at the articular surface of the ankle joint, adjacent to the fibula dissection was taken down to the subcutaneous tissues, they were divided. Extensor tendons were retracted. Dissection was taken through the capsule and the hematoma from the fracture was…

OP Report Sample for Idiopathic Lenke 3 scoliosis

PREOPERATIVE DIAGNOSIS: Idiopathic Lenke 3 scoliosis.

POSTOPERATIVE DIAGNOSIS: Idiopathic Lenke 3 scoliosis.

OPERATION PERFORMED
• Posterior lumbar instrumentation T2-L4.
• Posterior lumbar fusion T2-L4.
• Posterior type 1 swab osteotomies from T2-T5 and from T11-L3 and posterior type 2 swab osteotomies from T6-T10 for the purpose of a posterior release.
• Allograft.
• Local bone graft.

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 1800 mL.

IV FLUIDS: 4000 mL of crystalloid, 4 units of packed RBC's, 4 units of FFP, and 260 mL of Cell Saver.

OPERATION:
The patient was intubated in supine position with full ASA monitoring. SCD's were applied. Foley's catheter was placed. Neuromonitoring leads were applied. Patient was placed prone on the Jackson operating table. Pressure points were well padded. The back was adequately scrubbed, painted, and draped in usual sterile fashion. An adequate time-out was performed. A skin incision of adequate length w…