Colonoscopy with Forceps Polypectomy Operative Sample Report
DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
PREOPERATIVE DIAGNOSIS: History of adenomatous colon polyps, last removed five years ago.
POSTOPERATIVE DIAGNOSES:
1. Recurrent polyp of sigmoid colon.
2. Small to moderate-sized internal hemorrhoids.
PROCEDURE PERFORMED: Colonoscopy with forceps polypectomy.
SURGEON: Jane Doe, MD
MEDICATIONS: Demerol 125 mg IV and Versed 5 mg IV.
DESCRIPTION OF PROCEDURE: Informed consent was obtained after explanation of the risks, benefits, and alternatives of the procedure. Specific risks discussed with the patient included, but were not limited to, risk of bleeding, infection, perforation, missed polyps, and sedation.
The patient was premedicated in order to obtain conscious sedation. Rectal examination was unremarkable. The prostate gland was mildly enlarged consistent with the patient’s age. Next, a video colonoscope was inserted into the rectum and gently advanced to cecum under direct visualization without difficulty.
Preparation was very good. Cecum was identified by the appendiceal orifice and ileocecal valve. The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal. The mid sigmoid colon had a 4-5 mm sessile polyp. It was removed in a couple of bites using forceps polypectomy technique.
There was excellent hemostasis. The polyps were retrieved and sent to pathology. The rectum had small to moderate-sized internal hemorrhoids seen on the frontal and retroflexion view. The patient tolerated the procedure well and was returned to the recovery unit in stable condition. The previously seen mild proctitis on his colonoscopy five years ago had completely resolved. Greater than 10 minutes were spent examining the mucosa between the cecum and the rectum.
IMPRESSION:
1. Recurrent colon polyps, status post removal.
2. Small to moderate-sized internal hemorrhoids.
PLAN:
1. Check results of colon polyp pathology. If there are no ominous changes, we will repeat colonoscopy in five years.
2. Call office for biopsy results in one week.
3. Follow up with Dr. John Doe as regularly scheduled.
