DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Change in bowel habits.
POSTOPERATIVE DIAGNOSIS:
Two small sessile polyps in the proximal ascending and hepatic flexure.
PROCEDURE PERFORMED:
Colonoscopy to the cecum, cold biopsy and polypectomy of proximal ascending colon, cold biopsy and polypectomy of small sessile polyp in the hepatic flexure.
SURGEON: John Doe, MD
SEDATION: IV sedation.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old gentleman who reported change in bowel habits over the last month. The patient states that he has had constipation requiring straining for bowel movement. The patient states he has also had change in the caliber of his stool. The patient presents at this time for colonoscopy. The procedure including the risks, benefits, potential complications such as bleeding and perforation, were discussed with the patient. The patient understood and agreed to proceed.
PROCEDURE FINDINGS: The patient had a normal colonoscopy to the cecum. The patient’s bowel prep was fair. There were areas of thick liquid stool present. There were two small sessile polyps noted; one in the proximal ascending colon, one at the hepatic flexure. Both these polyps were approximately 1 cm in size or less.
DESCRIPTION OF PROCEDURE: The patient was brought into the endoscopy suite and laid in the left lateral decubitus position. The patient was given IV sedation, and the anorectal examination was performed. The colonoscope was placed into the rectum and advanced into the cecum without difficulty. The scope was noted to be in the right lower quadrant by transillumination light and palpation. The scope was noted to be in the cecum by identifying the ileocecal valve and the appendiceal orifice. The scope was brought back out. Note that the terminal ileum could not be easily intubated. In the proximal ascending colon, there was a small sessile polyp noted, approximately 1 cm in size, that was removed completely using cold biopsy forceps. The area was irrigated and there was no active bleeding noted.
Scope was withdrawn further, and during this examination of the mucosa, repeated irrigation was required to evaluate the mucosa. The patient’s bowel prep was fair with areas of thick, green liquid stool present. In the hepatic flexure, there was a sessile polyp of approximately 1 cm in size, which was removed completely using cold biopsy forceps, and the area was irrigated. There was no active bleeding noted. The scope was brought back further. There were no other abnormalities noted. There were no obvious diverticula noted. In the rectum, the scope was retroflexed where some hemorrhoidal tissue was noted. No other abnormalities were noted.
The scope was placed in the lumen and excess air aspirated. The patient tolerated the procedure well without any complications. The patient will be instructed to call later this week for biopsy results.
