DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Tethered cord at L3, L4 and L5.
POSTOPERATIVE DIAGNOSIS:
Tethered cord at L3, L4 and L5.
PROCEDURE PERFORMED:
Reopening of previous incisions and tethering of the cauda equina.
SURGEON: John Doe, MD
COMPLICATIONS: None.
SPECIMENS: None.
DESCRIPTION OF PROCEDURE: The patient was intubated and placed in the prone position. Motor response, somatosensory-evoked responses, EMG and rectal tone were monitored throughout the procedure. The incision site was prepped and draped in sterile fashion. An incision was made with a 10 blade scalpel and Bovie coagulators and the muscle opened and the scar tissue gradually trimmed. Then, the dura was opened with a 15 blade. Under the microscope for microdissection illumination, the scarred nerve roots were progressively freed up from the dura. By using intraoperative stimulation, the nerve roots were identified and differentiated from the scar tissue. At the end of the surgery, from the L3 to L5-S1, the entire cauda equina was completely freed up from the dura scar tissue. Then, a piece of Gore-Tex was used to patch the dura, which was closed with 5-0 Prolene. The area was reinforced with Tisseel and a piece of DuraGen. The incision was closed in layers with 0 Vicryl, 2-0 Vicryl and 3-0 Vicryl and nylon for the skin. In the subcutaneous area, a Jackson-Pratt drain was left for drainage.
Neurosurgery Operative MT Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Bilateral periventricular lesions.
POSTOPERATIVE DIAGNOSIS:
Bilateral periventricular lesions.
PROCEDURE PERFORMED:
Right image-guided stereotactic biopsy of the right periventricular lesion.
SURGEON: John Doe, MD
COMPLICATIONS: None.
SPECIMENS: Biopsy.
DESCRIPTION OF PROCEDURE: The patient was intubated and placed in the supine position with the head in the Mayfield head rest. The head of the patient was registered to the image guidance system and a trajectory was selected from the right middle temporal lobe to the periventricular lesion. The area was then prepped and draped in the sterile fashion. The incision was made with 10 blade scalpel, Bovie coagulators, and the Midas Rex was used to create a bur hole. The hole was enlarged with a punch and then the trajectory was re-selected. A biopsy needle holder was placed and the selected area was then biopsied 4 times. The specimens were sent to pathology and the preliminary answer was lymphoma. After that the dura was closed and patched with a piece of DuraGen. The bony defect was then replaced with a bur hole cover and fixed to a miniplate and then incision was closed with 2-0 Vicryl and staples.
Neurosurgery Operative MT Sample Report #3
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Hydrocephalus.
POSTOPERATIVE DIAGNOSIS:
Hydrocephalus.
PROCEDURE PERFORMED:
Ventriculoperitoneal shunt with endoscopic placement of peritoneal catheter.
SURGEON: John Doe, MD
COMPLICATIONS: None.
SPECIMENS: None.
DESCRIPTION OF PROCEDURE: The patient was intubated and placed in the supine position with the head tilted to the left. An incision was marked in the right frontal area, the posterior parietal area and the abdominal wall. The incisions were prepped and draped in sterile fashion. The first incision was made in the right frontal area, where the bur hole was marked and made with a Midas Rex. The ventricular catheter was inserted into the ventricle with immediate exit of spinal fluid. This was connected to a programmable valvulotome that was set at 120 mm of water. The programmable valvulotome was then connected to the peritoneal catheter, which was passed with the use of a tunneler from the abdominal wall to the posterior parietal and then to the frontal area. Upon connections of all these parts, CSF was falling normally from the peritoneal catheter. Subsequently, the area was irrigated with antibiotic solution and the frontal incision was closed with 3-0 Vicryls and 3-0 nylon. The posterior parietal incision was closed with 2 staples and the abdominal incision was closed after endoscopic placement of the catheter into the peritoneal cavity.
Neurosurgery Operative MT Sample Report #4
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Hydrocephalus.
POSTOPERATIVE DIAGNOSIS:
Hydrocephalus.
PROCEDURE PERFORMED: Ventriculoperitoneal shunt.
SURGEON: John Doe, MD
COMPLICATIONS: None.
SPECIMENS: None.
DESCRIPTION OF PROCEDURE: The patient was intubated and placed in the supine position with the head tilted to the left. An incision was marked on the right side of the frontal area in the posterior parietal and abdominal area on the right side. The areas were all prepped and draped in sterile fashion. An incision was made at the level of the frontal region. Then, with a Midas Rex, bur hole was made. A ventricular catheter was inserted into the ventricle with exit of spinal fluid under high pressure. The ventricular catheter was connected to the programmable valve set at 120 mm of water. Then, an incision was made in the right upper quadrant of the abdomen, and with use of a passer, a peritoneal catheter was passed from the frontal area to the posterior parietal, including the abdominal wall. At this point, the abdominal wall was dissected in layers and the peritoneum was opened and the peritoneal catheter was inserted into the peritoneal cavity after verification of appropriate functioning of the system. Then, all areas were irrigated with antibiotic solution and the incisions were closed as follows: The right frontal with 3-0 Vicryls and 3-0 nylon, small posterior parietal incision closed with 2 staples and the abdominal wall closed with 2-0 Vicryls, 3-0 Vicryls and staples.
