DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiparity.
POSTOPERATIVE DIAGNOSIS: Multiparity.
PROCEDURE PERFORMED: Postpartum tubal ligation.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: After informed consent was signed, this (XX)-year-old Hispanic female was taken to the operative suite and placed in the supine position. She had her abdomen appropriately prepped and draped and bladder emptied sterilely. The area above the umbilicus was injected with Marcaine and Xylocaine mixture.
Next, a skin incision was made and the fascia was injected likewise. Entry into the abdominal cavity was performed. The patient was placed in the Trendelenburg position. The right fallopian tube was grasped and brought over the incision. A window was made in the mesosalpinx. The proximal and distal tube was clamped, mid section removed, and tied with 2-0 plain gut in order to fall back into the abdomen.
A similar procedure was done on the left. The fascia was closed with Vicryl and skin with 4-0 undyed Vicryl. Blood loss was minimal. The patient was taken to the recovery room in stable condition. The patient will be discharged tomorrow.
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. One day postpartum.
2. Desires permanent sterilization.
POSTOPERATIVE DIAGNOSES:
1. One day postpartum.
2. Desires permanent sterilization.
PROCEDURE PERFORMED: Postpartum tubal ligation.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. She had epidural left in place through the night. However, this was ineffective when dosing, so she did have intubation. After intubation, a knife was used to make approximately a 3 cm incision in the umbilicus linearly. This was taken down sharply to the rectus sheath, which then extended with knife sharply.
After this, peritoneum was then tented up and entered sharply with scissors. The retractor was then placed and angled so that the tube could be grasped with Babcock clamp. First, the patient’s left tube was grasped. This was then brought up through the operating field. Bovie cautery was used on the mesosalpinx and then 0 chromic sutures were tied sequentially on the distal ends. The tube was then cut and then sutures were cut.
The exact same procedure on the opposite site was followed. The segment of the tube was isolated. Mesosalpinx was opened. Two stitches of 0 plain were used to tie sequentially. The segment of the tube was removed followed by cutting of the suture stitches.
At this point, all instruments were removed. The edges of the fascia were grasped with two Allis clamps. A 2-0 Vicryl was used to secure these edges in a running suture followed by 3-0 subcutaneous, followed by 4-0 subcuticular and Band-Aid was placed. The patient was then awoken, extubated, and transferred to the recovery room in stable condition.
Ob/Gyn Transcription Samples 1
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Desires permanent sterilization.
POSTOPERATIVE DIAGNOSIS: Desires permanent sterilization.
PROCEDURE PERFORMED: Postpartum tubal ligation, Parkland method.
SURGEON: John Doe, MD
ANESTHESIA: Epidural.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 200 mL.
FLUID REPLACEMENT: 500 mL of lactated Ringer’s.
DESCRIPTION OF PROCEDURE: The patient was brought back to the operating room where anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion. A small infraumbilical incision was made with a scalpel and carried through to the underlying fascia with Bovie. The fascia was entered with Metzenbaum scissors and extended laterally.
The left fallopian tube was identified, grabbed with a Babcock, and walked out to the fimbriae. A small window was made with Bovie. Two plain gut ties were passed through. The tube was ligated and cut.
Attention was then turned to the right side where, in a similar fashion, the fallopian tube was identified, grasped with a Babcock, walked out to the fimbriae. A window was then made with a Bovie. Plain gut ties were passed through. The tube was ligated and cut.
Hemostasis was found to be adequate with both tubes. The fascia was then closed with 0 Vicryl in a running fashion. The subcutaneous tissue was reapproximated with 3-0 Vicryl and the skin was closed with 4-0. The patient tolerated the procedure well and was taken back to the recovery room in stable condition.
Ob/Gyn Transcription Samples 2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Multiparity, desires permanent sterilization.
POSTOPERATIVE DIAGNOSIS: Multiparity, desires permanent sterilization.
PROCEDURE PERFORMED: Postpartum tubal ligation, Pomeroy method.
SURGEON: John Doe, MD
ANESTHESIA: Epidural.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 10 mL.
FLUIDS: 700 mL of lactated Ringer’s.
FINDINGS: Normal uterus, tubes, and ovaries. There were some slight adhesions, anterior abdominal wall, on the right side.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, where epidural was found to be adequate. A small transverse infraumbilical skin incision was then made with the scalpel. The incision was carried down through the underlying fascia with blunt dissection until the peritoneum was identified and entered the peritoneum. At the site of the incision, it was noted to be free of adhesions. The incision was then extended with Metzenbaum scissors.
The patient’s left fallopian tube was then identified and brought to the incision by grasping it with the Babcock clamp. The tube was then followed out to the fimbria. The Babcock clamp was then used to grasp approximately 4 cm from the cornua region, clamped with the hemostat. A plain gut tie was then used to occlude the tube. A second tie was used as well. Attention was then turned to the right tube and ovary, which in similar fashion was grasped with a Babcock, brought to the incision, and clamped with the hemostat and then tied behind the clamp. The tube was then cut and removed and then returned to the abdomen.
The fascia was then closed in a single layer using 3-0 Vicryl. The skin was closed in a subcuticular fashion using 3-0 Vicryl on a Keith needle. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room in stable condition.
PATHOLOGY: Segments of right and left fallopian tubes.
