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SAMPLE
REPORTS
Operative
Report #1
Operative Report #2
OPERATIVE
REPORT #1
PREOPERATIVE
DIAGNOSIS: Thrombosed
hemorrhoids.
POSTOPERATIVE
DIAGNOSIS: Same.
PROCEDURE
PERFORMED: Hemorrhoidectomy
times three.
SURGEON:
Dr. Daffy Duck
ANESTHESIA:
General.
FINDINGS:
Large, circumferential prolapsed hemorrhoids, with
partial thrombosis. Three
of the largest hemorrhoids were excised, without complication.
There was still hemorrhoidal tissue left at the
conclusion, but I did not feel it was safe to do any further
excision.
SPECIMEN:
Hemorrhoids.
CULTURES:
None.
DRAINS:
None.
ESTIMATED BLOOD
LOSS: 50 cc.
DRESSINGS:
Xeroform pack and ABD.
COMPLICATIONS:
None.
CONDITION:
Stable.
OPERATIVE
INDICATIONS: This
is a 20-year-old female, one week postpartum, who presented to
my clinic with excruciatingly painful hemorrhoids. She had had previous thrombosed hemorrhoid which was incised
and drained in the clinic earlier in the pregnancy. She has not had a bowel movement in a week due to pain.
On exam she had circumferential prolapsed hemorrhoids
with partial thrombosis in multiple areas.
I discussed hemorrhoidectomy with the patient and her
sister. They
understood and wished to proceed.
DESCRIPTION OF
PROCEDURE: The
patient was identified in the holding area and brought to the
operating room where she was placed in the supine position.
After induction of general anesthesia, she was prepped
and draped in the usual sterile fashion. The legs were brought up in the lithotomy position and a
retractor was placed in the anus.
Very prominent, large, partially thrombosed, external
hemorrhoid was identified at 7-8 o'clock in the lithotomy
position. It was
grasped with a hemorrhoidal clamp. A 2-0 chromic stitch was placed at the apex.
The Bovie electrocautery was then used to elliptically
excise the large hemorrhoid, staying superficial to the
sphincter muscle. Hemorrhoid
was then passed off as specimen.
Further bleeding was controlled with Bovie
electrocautery. The
mucosa was closed with a running chromic stitch, leaving the
end-point epidermis open.
Two other very
large hemorrhoids with thrombosis were then identified, at the
5 o'clock position in lithotomy and at the 10-11 o'clock
position. These
two hemorrhoids were excised in the exact same fashion as the
first hemorrhoid. At
the conclusion, there was no evidence of bleeding.
There was still some prominent hemorrhoidal tissue
remaining. However,
I did not feel any further excision would be safe at this
time.
Xeroform wrapped
around 4x4s was then placed in the anus as a dressing and ABD
placed over the top. The
patient was then awakened and taken to the recovery room in
good condition. There
were no operative complications.
OPERATIVE
REPORT #2
Top
of Page
PREOPERATIVE
DIAGNOSIS: Retained
abdominal sutures.
POSTOPERATIVE
DIAGNOSIS: Same.
ATTENDING
SURGEON: Dr.
Elmer Fudd.
RESIDENT
SURGEON: Dr.
Daffy Duck.
ANESTHESIA:
MAC.
ESTIMATED BLOOD
LOSS: Minimal.
COMPLICATIONS:
None. The
patient tolerated the procedure well.
PROCEDURE
PERFORMED: Removal
of abdominal sutures.
DESCRIPTION OF
PROCEDURE: The
patient was brought to the operating room where she was placed
comfortably supine on the operating table.
She was then placed under the care of the
anesthesiologist for monitored anesthesia.
The abdomen was prepped and draped in the usual sterile
fashion. A total
of 4 cc of 1% lidocaine with 1:100,000 epinephrine was
injected subcutaneously down the midline of the abdomen, over
the previously-healed incision.
Using a #15
Bard-Parker surgical blade, six small incisions of
approximately 1.5 cm in length were made over the
previously-healed incision in the midline.
Using hemostats, blunt dissection was performed in
order to locate the abdominal sutures.
In this manner, the sutures were located and
subsequently removed from the abdomen.
The incisions were then closed with a 4-0 Vicryl
subcuticular suture. Steri-Strips
were placed over the wounds, followed by placement of a
bandage that was secured with tape.
The patient
tolerated the procedure well.
On being taken from the operating room, her vital signs
were stable and she had spontaneous respirations.
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