DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Fourth-degree vaginal prolapse.
POSTOPERATIVE DIAGNOSIS: Fourth-degree vaginal prolapse.
PROCEDURE PERFORMED: Colpocleisis.
SURGEON: John Doe, MD
ANESTHESIA: General.
FINDINGS: Total vaginal prolapse. The cervix and uterus were surgically absent.
ESTIMATED BLOOD LOSS: 15 mL.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position on the operating table, where general anesthesia was administered. The patient was then placed in the dorsal lithotomy position. Examination under anesthesia was performed. She was prepped and draped in the usual manner for vaginal surgery. Initially, the prolapse was explored to identify what would be the apex. A Kocher clamp was placed on either side of the midline at this apex area. A transverse incision was made with the scalpel between these 2 Kocher clamps and the Metzenbaum scissors was then used to undermine and incise the vaginal mucosa from this point up to a point approximately 3-5 cm shy of the urethral meatus. The vaginal mucosa was dissected off of the underlying fascia with blunt and sharp dissection on either side, similar to what would be done for anterior vaginal repair. Then, approximately a 5 cm width of underlying fascia had been exposed. The excess vaginal mucosa was then trimmed off. At this point, any bleeding was controlled with the Bovie apparatus and a Kocher clamp was placed on either side of the midline of the vaginal introitus posteriorly. A triangular shaped section of skin was excised off the perineal body using the scalpel, the base of the triangle between the 2 Kocher clamps and the apex superior to the anal verge. The vaginal mucosa was then undermined and incised in the midline up to the vaginal apex point, again using Metzenbaum scissors. The vaginal mucosa was then dissected off the underlying fascia on either side of the midline using blunt and sharp dissection as would usually be done in a posterior repair. When a similar width of fascial tissue had been exposed, as on the anterior surface, again the excess vaginal mucosa was excised off either side. At this point, starting at the apex, 5-0 Vicryl sutures were placed in vertical mattress fashion, taking a bite of tissue anteriorly, crossing the apex and then taking a bite of tissue posteriorly. After 5 such mattress sutures were placed, they were cinched up and tied. Following this, another layer of sutures were placed in a similar fashion. In this manner, the anterior vaginal surface was sutured to the posterior vaginal surface and several such layers of this suturing technique were performed until the vagina was closed. At this point, the exposed fascial surface was closed over with remaining vaginal mucosa, gathered from the left and the right sides and closed with a running locking suture in a vertical orientation, starting inferior to the urethra and working posteriorly to the vaginal introitus. This left the perineal body exposed. A crown suture was placed on either side to shore up the vaginal introitus and the skin was reapproximated over the defect in the perineal body with a layer of running subcutaneous suture, followed by a layer of subcuticular suture to close the perineal body and effect a perineoplasty. At this point, a Foley catheter was inserted in the bladder using sterile gloves. The patient was returned to the supine position, awakened from anesthesia without any difficulty and transferred to the recovery room in good condition. The patient tolerated the procedure well. There were no complications.
*****************************************************************
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Persistent low-grade squamous intraepithelial lesion.
POSTOPERATIVE DIAGNOSIS: Persistent low-grade squamous intraepithelial lesion.
PROCEDURE PERFORMED: LEEP cone biopsy.
SURGEON: John Doe, MD
ANESTHESIA: Local.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
PROCEDURE FINDINGS: A small area of the cervix with no uptake of Lugol solution.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the table in the dorsal lithotomy position. The speculum was placed in the vagina. The Lugol’s was used both as a strong iodine disinfectant as well as to light up any abnormal areas in the cervix. Using the green loop and 50 watts of cutting energy, a flat-shaped cone biopsy was removed from the superficial area of the cervix and sent to pathology. Using 50 watts of coagulation energy, the ectocervix surrounding that area as well as any bleeding areas in the cervix, in the bed of the removed cone, were coagulated. Hemostasis was adequate. Surgicel was placed in the cervical area for better hemostasis later. This was explained to the patient. The patient was in good condition and tolerated the procedure well. The patient was sent back to same-day surgery where she was going to be discharged from.
More Ob-Gyn Sample Reports Some More Ob-Gyn Sample Reports Ectopic Pregnancy Removal Sample
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Missed abortion.
POSTOPERATIVE DIAGNOSIS: Missed abortion.
PROCEDURE PERFORMED: Suction dilation and curettage.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100 mL.
PROCEDURE FINDINGS: Exam under anesthesia revealed an 8-week retroverted uterus and moderate amounts of products of conception.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was initiated without difficulty. The patient was then prepped and draped in the normal sterile fashion in dorsal lithotomy position. Exam under anesthesia was performed and findings were as above. A weighted speculum was placed in the posterior vagina and the anterior lip of the cervix was grasped with an Allis clamp. The uterus was then gently sounded to 8 cm and sequentially dilated with Hanks dilators. An 8 mm suction curette was then introduced into the uterine cavity and rotated to clear the uterus of products of conception. The suction curette was then removed and a medium sharp curette was then used to perform an endometrial curettage until gritty texture was noted. The suction curette was then reintroduced to clear the uterus of remaining products of conception. The patient tolerated the procedure well. All instruments were removed from the vagina and the patient was awakened and taken to the recovery room in good condition.
Ob Gyn Surgical Instrument Word List Ob-Gyn Operative Sample Reports
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Sterilization.
POSTOPERATIVE DIAGNOSIS: Sterilization.
PROCEDURE PERFORMED: Laparoscopic bilateral tubal cauterization.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Minimal.
PROCEDURE FINDINGS: An 8-week retroverted uterus, grossly normal-appearing ovaries bilaterally and normal ovaries and cul-de-sac.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was initiated without difficulty. The patient was then prepped and draped in a normal sterile fashion in the dorsal lithotomy position. The bladder was catheterized and an examination under anesthesia was performed with findings as above. A weighted speculum was then placed in the posterior vagina and the anterior lip of the cervix was grasped with a single-tooth tenaculum. An acorn uterine manipulator was introduced into the endocervical canal and attached to previously placed tenaculum for uterine manipulation. A 10 mm infraumbilical skin incision was then made with a scalpel. A Veress needle was tested and entered into the peritoneal cavity without difficulty. After peritoneal placement was confirmed with the saline drop test, CO2 was infused through this port to create a pneumoperitoneum. After adequate pneumoperitoneum was created and the Veress needle was removed, a 10 mm nonbladed trocar and port was then introduced into the peritoneal cavity without difficulty. The laparoscope was then introduced and the survey of the bowel below the incision site was performed and there was noted to be excellent hemostasis. The blunt probe was then used to identify the tubes bilaterally to the fimbriated ends bilaterally. Kleppinger bipolar forceps was then used to cauterize approximately 3 cm portion of the isthmus of the tubes bilaterally. There was noted to be excellent hemostasis. Instruments were then removed from the peritoneal cavity and the laparoscope was removed and CO2 was released. The port was then removed and the skin was closed in a subcuticular fashion with 4-0 Vicryl. The instruments were then removed from the vagina and the patient was awakened and taken to the recovery room in good condition.
*****************************************************************
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES: Cystocele, rectocele and urinary stress incontinence.
POSTOPERATIVE DIAGNOSES: Cystocele, rectocele and urinary stress incontinence.
PROCEDURE PERFORMED: Anterior and posterior colporrhaphy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 600 mL.
PROCEDURE FINDINGS: Third-degree cystocele, third-degree rectocele, minimal uterine prolapse, no enterocele identified and small retroverted uterus.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was initiated without difficulty. The patient was then prepped and draped in the normal sterile fashion in dorsal lithotomy position in Allen stirrups. The bladder was catheterized and exam under anesthesia was performed with findings as above. The perineal body was then grasped with 2 Allis clamps and a triangular incision was made on the perineal body with the scalpel and this perineal skin was dissected off the underlying fascia with the scalpel. The posterior vagina was then injected with normal saline to aid in identification of the planes. Using Metzenbaum scissors, the underlying vaginal mucosa was undermined off the fascia in the midline to approximately 1 cm distal to the cervix. The edges of the rectocele were then grasped with Allis clamps. The vaginal mucosa was dissected along the underlying layer of fascia with the Metzenbaum scissors. There was noted to be extensive amounts of oozing from the underlying fascia, which was controlled with cautery. After an adequate dissection was performed bilaterally, the vertical mattress sutures were used to displace the rectocele inferiorly. Interrupted vertical mattress sutures of 0 Vicryl were used to displace the rectocele inferiorly. The excessive vaginal skin was then trimmed and the vaginal mucosa was reapproximated in a running interlocking fashion with 2-0 Vicryl. The bulbocavernosus muscles were then reapproximated with interrupted sutures of 2-0 Vicryl and the skin was closed in subcuticular fashion with 3-0 Vicryl. Attention was then turned to the anterior colporrhaphy portion of this procedure. The vaginal mucosa was then injected in the midline with normal saline. The vaginal mucosa was scored in the midline with the Bovie approximately 1 cm medial to the urethral meatus to 1 cm distal to the cervix. This vaginal mucosa was then undermined and then incised in the midline with the Metzenbaum scissors. The lateral aspects of the vaginal mucosa were then grasped with the Allis clamps and the vaginal mucosa was then dissected off the underlying fascia with the Metzenbaum scissors. Again, there was noted to be quite a bit of oozing at the incision, which was controlled with cautery. After adequate dissection was performed, bilaterally, vertical mattress sutures of 0 Vicryl were used to elevate the cystocele superiorly with the Kelly clamp. Interrupted vertical mattress sutures of 0 Vicryl were used to elevate the cystocele superiorly. The excessive vaginal mucosa was then trimmed with the Metzenbaum scissors and the vaginal mucosa was then reapproximated in the running interlocking fashion with 2-0 Vicryl.
Neonatal / Infant Discharge Summary Sample Infant / Child Physical Exam Samples
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right adnexal mass.
POSTOPERATIVE DIAGNOSIS: Struma ovarii.
PROCEDURES PERFORMED: Exploratory laparotomy, pelvic washings and right salpingo-oophorectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 50 mL.
PROCEDURE FINDINGS: A 9.5 x 10 cm multiloculated right ovary, the preliminary pathology was struma ovarii; normal-appearing uterus, left tube and ovary; normal cul-de-sac.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was initiated without difficulty. The patient was prepped and draped in the normal sterile fashion in the dorsal supine position. A Pfannenstiel skin incision was made with a scalpel and this incision was carried down to the underlying layer of fascia with cautery. The fascia was nicked in the midline and the fascial incision was extended laterally with the Mayo scissors. The inferior aspect of this incision was then grasped with 2 Kocher clamps, tented up and the underlying rectus muscles dissected off with the Mayo scissors. A similar procedure was performed on the superior aspect of this incision. The rectus muscles were then separated in the midline and the peritoneum identified and entered sharply with the Metzenbaum scissors. This incision was extended superiorly and inferiorly with good visualization of the bladder. The survey of the pelvis was performed with findings as above. The right adnexa was then delivered through the incision. The infundibulopelvic ligaments were then clamped with Heaney clamps, transected and suture ligated with 0 Vicryl. The remainder of the ovary was dissected off the mesosalpinx and clamped with the Heaney clamp and transected and suture ligated with 0 Vicryl. The ovary was then sent to pathology for frozen section. After inspecting the right tube, there was question as to whether there was ovarian tissue present and possibly raising the question of future ovarian remnant syndrome. The decision was made at this time to remove the right tube. The right tube was clamped at the level of the uterine cornua with a Kelly clamp, transected and suture ligated with 0 Vicryl. The mesosalpinx was then sequentially clamped with Kelly clamps, transected and suture ligated with 0 Vicryl. There was noted to be excellent hemostasis. The peritoneum was then reapproximated in a running fashion with 2-0 Vicryl and the fascia was closed in a running fashion with 0 Vicryl. The subcutaneous fat was irrigated and all bleeders coagulated. The subcutaneous fat was then reapproximated with interrupted sutures of 3-0 Vicryl and the skin was closed in a subcuticular fashion with 4-0 Vicryl. The patient tolerated the procedure well and was awakened and taken to the recovery room in good condition.
