DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
OPERATION PERFORMED: Open appendectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMEN: Obtained and sent for evaluation.
DISPOSITION: To the recovery room.
INDICATIONS FOR OPERATION: This is a (XX)-year-old with acute appendicitis.
CONSENT: The risks, benefits, and alternatives of appendectomy were discussed with the patient’s parents, and they agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the table in the supine position. Preoperative antibiotics had been administered. General anesthetic was then induced. The abdomen was prepped and draped in usual sterile manner.
A local anesthetic was infiltrated into the right lower quadrant and a small incision was made. Dissection was carried down to the fascia. The external oblique was sharply divided. The muscles were retracted apart. The peritoneum was then incised. Some nonpurulent fluid was obtained, and this was sent for culture. The appendix was easily identified. The cecum was carefully brought out of the incision using a moistened Ray-Tec. The mesoappendix was divided between clamps and tied. The appendix was then stapled at its base using a vascular stapler. The staple line was examined; it was intact and hemostatic. Hemostasis was also assured at the mesoappendix. The cecum was then reduced back into the abdominal cavity and irrigation was then performed.
The wound was then closed in layers. The peritoneum was closed with a running 2-0 Vicryl suture. The rest of the layers were closed with interrupted 0 Vicryl sutures. The skin was irrigated and then closed in layers. The dermis was reapproximated with 3-0 Vicryl suture, and the skin was closed with running 4-0 Vicryl subcuticular stitch. Sterile dressings were applied. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. The specimen was sent for routine evaluation.
