Operative Report Samples (10)

Medical operative report samples:

OPERATIVE REPORT SAMPLE #1

DATE OF OPERATION:	03/08/10
PREOPERATIVE DIAGNOSIS:	Dermatochalasis OU.
POSTOPERATIVE DIAGNOSIS:	Dermatochalasis OU.
OPERATIVE PROCEDURE:	Bilateral upper lid blepharoplasty.
SURGEON:	Harry Richard, M.D.
ANESTHESIA:	Local with Monitored Anesthesia Care.
COMPLICATIONS:	None.

HISTORY OF PRESENT ILLNESS:Patient was taken from the preoperative area to the Operating Room and placed in the supine position. A time-out was taken and surgery was verified. Patient was then prepped and draped in the usual sterile fashion for ocular plastic surgery. A skin marker was then used to delineate the left upper lid crease along its lateral border. This was also done on the right upper lid. Green’s forceps were then used to grasp the tissue superior to the lid crease. The appropriate amount was grasped for planned removal. This area was then marked along the superior edge. The inner aspects of the markings were then joined and the lateral aspects of the markings were also joined. Close attention was paid to insure that no lagophthalmos was created. At this point, lidocaine 2.0% with epinephrine was then injected locally under the premarked skin area, on the left upper lid as well as the right upper lid. Cool compresses were placed on the lids. Attention was first paid to the left side where a #15 blade was then used to incise the skin along the area that was premarked. The skin was then initially removed using Westcott, and 0.12 and then with a Bovie. Hemostasis was achieved using the Bovie cautery as well. Then 6-0 Prolene suture was then used to close the incision with a running subcuticular stitch pattern. The ends were bolstered with small pieces of rubber band and tied to the Prolene suture. The wound was noted to be well approximated. No lagophthalmos was appreciated. The same technique was performed on the right upper lid with no lagophthalmos appreciated as well. Maxitrol and cold compresses were placed. Patient tolerated the procedure without any complications. Patient was instructed to take oral antibiotics and Topical TobraDex and follow up in one week with Dr. Richard in the eye clinic.

OPERATIVE REPORT SAMPLE #2

DATE OF OPERATION:	02/20/10
PREOPERATIVE DIAGNOSIS:	Bilateral ectropion with recurrent ptosis of the left eye.
POSTOPERATIVE DIAGNOSIS:	Bilateral ectropion with recurrent ptosis of the left eye.
OPERATIVE PROCEDURE:	Bilateral ectropion repair with upper blepharoplasty of the left eye.
SURGEON:	Harry Richard, M.D.
ANESTHESIA:	Local with monitored anesthesia care.
SPECIMEN:	Skin fat excised.
ESTIMATED BLOOD LOSS:	Less than 5 cc.
COMPLICATIONS:	None.
DRAINS:	None.

DESCRIPTION OF THE PROCEDURE: The patient was taken to the Operating Room and was placed in a recumbent position. A time out was conducted in which the patient’s identity, surgical eyes and procedure was verified by the surgeon, circulating nurse and scrub nurse. Using a Colorado needle, an initial incision in the lower eyelid margin on the premarked skin area was performed. The skin was undermined and bleeding vessels were carefully cauterized with a held cautery. The spectrum was opened and excess fat was removed and a lateral tarsorrhaphy was performed as well. The skin was closed with 6-0 plain suture. On the left upper eyelid, we also used a Colorado needle to make an initial elliptical incision on the premarked area of the skin. The skin was removed and it was closed with 6-0 Prolene suture. At the endo f the procedure, we gave 1 gm of Ancef and 8 mg of Decadron intravenously. The patient was sent to the Recovery Room without any complications where he received postoperative instructions and follow up appointments.

OPERATIVE REPORT SAMPLE #3

DATE OF OPERATION:	01/06/11
PREOPERATIVE DIAGNOSIS:	Torn lateral meniscus bucket-handle. Chondromalacia grade III of the patella.
POSTOPERATIVE DIAGNOSIS:	Torn lateral meniscus bucket-handle. Chondromalacia grade III of the patella.
OPERATIVE PROCEDURE:	Right knee lateral meniscectomy. Chondroplasty grade III patellar chondromalacia. Autologous tissue transplant with platelet rich plasma.
SURGEON:	Harry Richard, M.D.
ASSISTANT:	Pamela Walker, P.A.
ANESTHESIA:	LMA general.

PROCEDURE IN DETAIL:The patient was prepped and draped in the standard fashion with a tourniquet on the leg after preoperative antibiotics. The tourniquet was set 300 mm of pressure. Inferomedial and inferolateral portals were established. The scope was passed through an inferolateral portal. Evaluation of the suprapatellar pouch demonstrated no major abnormalities although some synovitis. The patella, however, demonstrated grade III chondromalacia especially along the lateral facet and over to the middle portion of the patella. There was no significant chondromalacia in the femoral groove. The anterior cruciate ligament was intact. The medial compartment demonstrated no significant tears and no significant areas of chondromalacia. The lateral meniscus, however, demonstrated a large bucket-handle tear of the posterior horn and a flap tear in the body and anterior part of the meniscus. Initial attention was directed to the lateral meniscus where the flap tear and the bucket-handle tear were removed. This did not appear to be repairable. It was too damaged for an effective repair. The patient then underwent a trimming of it to a stable margin and once this had been established attention was directed to the patella. Initially, a mechanical debridement was done followed by a smoothing and rounding of the shoulders and edges with an ArthroCare on a setting of 2. This having been completed this, the knee was injected with platelet rich plasma to help healing, help hemostasis and prevent infection. She then was placed in a compressive dressing from toes to midthigh. She tolerated the procedure well and will be discharged home to be followed up in my office on Monday.

OPERATIVE REPORT SAMPLE #4

DATE OF OPERATION:	03/10/10
PREOPERATIVE DIAGNOSIS:	Cataract left eye.
POSTOPERATIVE DIAGNOSIS:	Cataract left eye.
OPERATIVE PROCEDURE:	Phacoemulsification with anterior chamber intraocular lens placement.
SURGEON:	Harry Richard, M.D.
ANESTHESIA:	Monitored anesthesia care.
COMPLICATIONS:	Rupture of the posterior capsule.

INDICATIONS FOR PROCEDURE: The patient has noticed visual loss and impairment of visual acuity in the left eye over the last phase after diagnosis and discussion of surgery, risk and benefits, the patient opted for cataract surgery in the left eye.

PROCEDURE IN DETAIL: The patient was identified prior to operative area and holding area the correct eye was identified with a YES. A peribulbar block was given in the reoperative area under normal conditions. The patient was brought into the operative suite were leads and monitors were placed. It was confirmed that the left eye was the operative eye. A lid spectrum was spectrum was fashioned in the operative eye and the area was approached from the temporal area. A small groove was made at the two o’clock position using a corneal scleral blade. An incision was made at the six o’clock position with a 1 mm keratome. The anterior chamber was filled with Tryphan blue to stain the capsule. Viscoelastic was then inserted into the eye. The two o’clock position was then entered with a 2.7 mm keratome and using the cystotome and Utrata complete capsulorrhexis was performed. At this point it was noted that the patient’s pupil dilated very poorly. Hydrodissection was made with BSS and a cannula. The nucleus was spin and noted free of attachments. The phacoemulsification unit was then used to do the chopping technique to remove the nucleus. This was done without any problems. Residual cortex was removed using the I & A hand piece. At this point, it was noted there was a small rent in the posterior capsule and it was elected to put an anterior chamber intraocular lens. The wound was opened to allow for an anterior chamber intraocular lens. This was inserted without any problems in the anterior chamber and the wound was closed with three interrupted 10-0 nylon sutures. The wound was tested for water tightness. The water tightness was complete. Miochol was inserted in the eye thus constricting the pupil and it appeared to be complete. The speculum was removed. Antibiotic medication was placed on the eye. A shield and a patch were placed on the eye and the drapes were removed. The reminder procedure without complications and there was no vitreous loss. The patient was taken to the Recovery Room where he recovered without any problems.

OPERATIVE REPORT SAMPLE #5

DATE OF OPERATION:	03/20/10
PREOPERATIVE DIAGNOSIS:	Chronic low back pain. Lumbar discogenic pain. Lumbar myofascial pain.
POSTOPERATIVE DIAGNOSIS:	Chronic low back pain. Lumbar discogenic pain. Lumbar myofascial pain.
OPERATIVE PROCEDURE:	Right L1-L2, L2-L3, L3-L4, L4-L5, L5-S1 facet blocks under fluoroscopic guidance five levels. Left L1-L2, L2-L3, L3-L4, L4-L5, L5-S1 facet block under fluoroscopic guidance five levels.
SURGEON:	Harry Richard, M.D.
ASSISTANT:	Pamela Walker, C.R.N.A.
ANESTHESIOLOGIST:	Caroline Moss, M.D.
ANESTHESIA:	Local plus IV conscious sedation.
COMPLICATIONS:	None.
BLEEDING:	None.

INDICATIONS FOR PROCEDURE: Severe intractable pain that was not responding to conservative medical therapy, physical therapy or previous epidural steroid injections.

DESCRIPTION OF THE PROCEDURE: The procedure, risks, and benefits were explained to the patient, all questions were answered and consent was obtained. Patient was taken to the Operating Room and place in a decubitus-prone position on the operating table. Monitors were applied and sedation started by the anesthesiologist.

Then the lumbosacral area was prepped and draped in under surgical sterile conditions. Using fluoroscopic guidance AP and oblique views the right L1-L2, L2-L3, L3-L4, L4-L5 and L5-S1 facets were located. The skin and subcutaneous tissues were infiltrated with 1.0% lidocaine, 1 ml per each level. Then a 22-gauge, 3-inch spinal needle was directed toward the facet joint at each level using fluoroscopic guidance, oblique view under tunnel vision technique. Correct needle tip placement was confirmed using AP and lateral views and aspiration was negative for CSF and blood at each level. No paresthesias were noted during the needle placement. Then 1 ml of 0.25% Marcaine and 10 mg of Kenalog were injected per level. The patient tolerated the procedure well.

Then the left L1-L2, L2-L3, L4-L5, L5-S1 were located under oblique view of fluoroscopic guidance. The skin and subcutaneous tissues were infiltrated with lidocaine 1.0%; 2 ml per level and then a 22-gauge, 3-inch spinal needle was directed toward the facet joint at each level using fluoroscopic guidance, oblique view under tunnel vision technique. Correct needle tip placement was confirmed using AP and lateral views and aspiration was negative for CSF and blood at each level. No paresthesias were noted during the needle placement. Then 1 ml of 0.25% Marcaine and 10 mg of Kenalog were injected per level. The patient tolerated the procedure well. No complications were noted. The patient was transferred to the Recovery Room in stable condition.

OPERATIVE REPORT SAMPLE #6

DATE OF OPERATION:	01/06/11
PROCEDURE:	Manipulation of left total knee replacement under anesthesia for lysis of internal adhesions
SURGEON:	Torn lateral meniscus bucket-handle. Chondromalacia grade III of the patella.
ANESTHESIA:	Right knee lateral meniscectomy. CIV Diprovan.

SURGICAL TECHNIQUE:Following the induction of IV Diprovan and inhalation of nitrous oxide, the gentle manipulation of the left total knee replacement was undertaken with audible lysis of adhesions. The manipulation was carried out to 115° of flexion, measured with a goniometer and minus 4° of full extension. Excellent stability of the knee stressed in full extension. Surgical wound well healed. The patient, following the manipulation, she was allowed to recover from her anesthesia and transported by a stretcher from the Operating Room to the Recovery Room in good condition.

OPERATIVE REPORT SAMPLE #7

DATE OF OPERATION:01/06/12

PREOPERATIVE DIAGNOSIS: Status post left recurrent cubital tunnel syndrome.
Carpal tunnel syndrome.

POSTOPERATIVE DIAGNOSIS: Status post left recurrent cubital tunnel syndrome.
Carpal tunnel syndrome.

OPERATIVE PROCEDURE:
Left carpal tunnel release.
Left cubital tunnel release.
Adjacent tissue closure elbow.
Flexor synovectomy.

SURGEON:	Harry Richard, M.D.
ANESTHESIA:	MAC.
COMPLICATIONS:	None.
DRAINS:	None.
ESTIMATED BLOOD LOSS:	Minimal.

JUSTIFICATION:The patient is a 32-year-old female, right hand dominant with a previous left carpal tunnel release, cubital tunnel release. The patient has had an increase in symptoms including muscle wasting and constant numbness. The release was done by another physician. A re-release will be performed with a transposition of the nerve.

OPERATIVE NOTE:The patient was taken to the Operating Suite, placed in the supine position. A tourniquet was applied to the left upper extremity and set at 250 mm Hg. The arm was prepped and draped in the usual sterile fashion. The area in the palm and the elbow were infiltrated with 2% lidocaine and 0.25% Marcaine by me as well as IV sedation. The arm was maximally elevated, exsanguinated and the tourniquet was inflated to its preset pressures.

The first aspect of the procedure was to go ahead and make an incision in the palm. This was extended down to the transverse carpal ligament, which had reformed with scar tissue and an open release of the carpal tunnel was done, both the palm and volar forearm through the limited incision. A synovectomy was also performed due to the heavy reactive synovial tissue encountered. The synovial tissue was submitted to Pathology. The area was irrigated with antibiotic solution. All bleeding was meticulously controlled. After complete release of the carpal tunnel and transverse carpal ligament release the incision was closed using 4-0 nylon interrupted sutures.

Following this, my attention was then directed at the elbow. The medial epicondyle region, from the previous scar, was then incised carefully removing thick hard scar tissue. After considerable amount of dissection the ulnar nerve was identified and completely released at this time. The nerve appeared hyperemic and compressed. A minor transposition of the nerve and partial submuscular was performed and the area was irrigated with antibiotic solution. The wound was closed using adjacent tissue closure using 5-0 Vicryl for the deep subcutaneous tissue layer and 4-0-nylon closure for the skin.

The patient had incision lines dressed with Xeroform gauge, fluff and 4-inch Kling. The patient had the hand maximally elevated in a stockinettesling.The patient tolerated the procedure well and all sponge counts, needle counts and instrument counts were correct postoperatively. The patient is aware of possible post surgical sequelae, post traumatic complications including but not limited to hypertrophic scar, wound dehiscence, wound infection, retracted scar, contracted scar, nerve compression, nerve injury, tendon injury, further wasting and numbness of the hand and the possible need for further revisional surgery and/or occupation therapy.

OPERATIVE REPORT SAMPLE #8

DATE OF OPERATION:02/23/12

PREOPERATIVE DIAGNOSIS:
1. Pterygium, visually significant right eye.

POSTOPERATIVE DIAGNOSIS:
1. Pterygium, visually significant right eye.

OPERATIVE PROCEDURE:
1. Ocular surface reconstruction with amnioticmembrane graft, right eye.

SURGEON:	Dr. Smith
ASSISTANT:	OR scrub nurse.
ANESTHESIA:	MAC.
SPECIMEN SENT:	None.
ESTIMATED BLOOD LOSS:	Pterygium of the right eye.

JUSTIFICATION:Subjective growth of corneal lesion and decreased vision in the above noted eye with chronic inflammation subjectively noted. Preoperatively all risks, benefits, general considerations and alternatives regarding the above noted surgery have been explained by myself to the patient including possible loss of vision, infection, double vision, recurrence, the need for additional surgery and the potential loss of the eye. The patient has acknowledged understanding and has preoperatively signed the informed operative consent. Advised of all potential ramifications of surgery the patient desires to undergo the above noted surgery.

PROCEDURE:Anesthesia was administered without complication. An oculopress was placed over the eye for an appropriate duration. Prior to the actual surgical procedure a time out was undertaken with the patient present on the Operating Room table. The surgeon, anesthesia provider and circulating nurse confirmed the patient’s name, operative side, operative site and the exact procedure to be performed. The patient was prepped and draped in the usual sterile fashion.

A wire lid speculum was used to open the eyelid. Two drops of Betadine 5.0% was placed on the eye for 1 minute. The ocular surface reconstruction was begun by removing the pterygium. A 57 blade was used to excise the pterygium in a lamellar fashion. The base of the pterygium was removed using a Westcott scissor. Cautery was used to obtain hemostasis. It was difficult to dissect the plane of the pterygium as there was diffuse corneal scarring. The stroma was scarred, as was the limbal area. Mitomycin-c 0.25 mg per ml was placed over the bare sclera for 30 seconds and the eye was copiously irrigated with several bottles of BSS. The amniotic membrane graft was placed over the area and cut to the approximate size. Fibrin glue was used to adhere the amniotic membrane graft over the area of bare sclera. There were no complications. The eye was lightly pressure patched and shielded, after placement of a contact lens, subconjunctival injection, and antimicrobial ointment. The patient was brought to the Recovery Room without incident. Preoperative study results, ramifications thereof were explained to the patient and a copy of the same was given to the patient. The patient was told to see the primary care physician over the next 48 hours with a copy of the same preoperative study results. The patient will be seen by me in 24 hours. The patient is given a postoperative instruction sheet and told to call me day and night for any reason whatsoever.

OPERATIVE REPORT SAMPLE #9

DATE OF OPERATION:	01/06/12
PREOPERATIVE DIAGNOSIS:	Right knee medial meniscal tear.
POSTOPERATIVE DIAGNOSIS:	Right knee medial meniscal tear osteochondral defect medial femoral condyle.
OPERATIVE PROCEDURE:	Right knee arthroscopic partial medial meniscectomy, chondroplasty medial femoral condyle
SURGEON:	Harry Richard, M.D.
ASSISTANT:	Pamela Walker, C.R.N.A.
ANESTHESIOLOGIST:	Caroline Moss, M.D.
ANESTHESIA:	General.
TOURNIQUET:	Tourniquet x 45 minutes.
ESTIMATED BLOOD LOSS:	25 cc.
COMPLICATIONS:	None.

SURGICAL TECHNIQUE:Patient was in the supine position under general anesthesia. Patient received prophylactics antibiotics prior to the surgical procedure. A tourniquet was placed around the right thigh area. The right lower extremity was placed in a leg holder. The right lower extremity was draped and prepped in the usual standard fashion. At the beginning of the procedure, the tourniquet was inflated up to 300 mm Hg. Using a scalpel, a stab wound incision was done at the superomedial aspect of the right knee for insertion of the in-flow cannula. The knee joint was distended. Using a scalpel, a stab wound incision was done in the inferolateral aspect of the right knee for insertion of the camera. The first compartment was the patellofemoral. There was high-grade chondromalacia in the patellofemoral compartment with fraying of the cartilage with some areas of degeneration.

Then the medial gutter was inspected with no evidence of loose bodies. The medial compartment was inspected. There was osteochondral defect in the medial femoral condyle of approximately 2 x 2 cm. In addition, there was a complex degenerative tear of the medial meniscus posterior horn throughout the body. There was also loss of cartilage at the tibial plateau. Under direct visualization, the inferomedial portal was done. The probe was inserted for inspection of the area. Several photographs were taken as evidence of our intraoperative findings and procedures. A partial meniscectomy was done using meniscal biters and the meniscal cutter. Then the chondral defect was debrided using the meniscal cutter for exposure of the subchondral bone. The subchondral bone then was debrided and also several holes were done using the fracture pick until the cruciate ligament was present and patent. The lateral compartment was intact with no evidence of meniscal tears or cartilage damage. Patellar gutter was inspected with no evidence of loose bodies. The tourniquet was released and the osteochondral defect was evaluated. There was active bleeding through the holes made with the fracture pick. Several photographs were taken as evidence of out intraoperative findings. The knee joint was drained and the instruments were removed.

Portal wounds were approximated with 3-0 nylon. The knee was injected with 25 cc of plain Marcaine 0.50%. Sterile dressing was applied over the surgical wound. The tourniquet was released during the procedure. Patient was taken to the Recovery Room after extubation in stable condition with no complications during or after the procedure.

OPERATIVE REPORT SAMPLE #10

DATE OF OPERATION:	02/20/10
PREOPERATIVE DIAGNOSIS:	Status post excision basal cell carcinoma left lower lid.
POSTOPERATIVE DIAGNOSIS:	Status post excision basal cell carcinoma left lower lid.
PROCEDURE:	Reconstruction of left lower lid with full-thickness lid repair.
SURGEON:	Harry Richard, M.D.
ANESTHESIA:	Local with sedation.
COMPLICATIONS:	None.

JUSTIFICATION FOR PROCEDURE: The patient had a previously biopsied basal cell carcinoma of the left lower lid excised by his primary care doctor earlier in the day. This resulted in a full-thickness lid defect of the temporal 1/3 of the lid.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought to the Operating Room.

A 50/50 mixture of Xylocaine 2.0% with epinephrine mixed with Marcaine 0.75% with epinephrine was injected into the left lower lid. The face was prepped and draped in the usual sterile fashion. There was a defect of the full-thickness lid. This defect was created into a triangle by excising inferiorly at the base of the defect with Stevens scissors. A 6-0 silk suture was then passed through the lid margin including tarsus, both the medial and temporal edges to oppose the two edges of the lid. Deep 6-0 Vicryl sutures were then placed to close the deep tissues. The skin was then closed with several more 6-0 black silk sutures which were tied down under the skin. At the end of the procedure, the lid was in good position. The patient tolerated the procedure well and left the Operating Room in good condition.

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