DATE OF OPERATION:  MM/DD/YYYY 

PREOPERATIVE DIAGNOSIS: Complex left adnexal mass.

POSTOPERATIVE DIAGNOSIS: Left ovarian dermoid cyst.

OPERATION PERFORMED: Laparoscopic left partial salpingo-oophorectomy.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal.

ANESTHESIOLOGIST: Jean Doe, MD

IV FLUIDS: Crystalloid.

ESTIMATED BLOOD LOSS: Less than 5 mL for this portion of the procedure.

DESCRIPTION OF PROCEDURE: After appropriate informed consent was obtained, the patient was taken to the operating suite, given general endotracheal anesthesia, and then prepped and draped in the usual sterile fashion in the dorsal supine position with a Foley catheter in place. I arrived after the gastric portion of the procedure had been performed by Dr. Doe and found there were 3 ports in place, specifically a 10 mm umbilical port, a 10 mm right lower quadrant port, and a 5 mm left mid quadrant port that had been removed.

I placed a 5 mm left lower quadrant port through a stab wound under direct visualization after carbon dioxide was insufflated. The ovary was grasped carefully. The Harmonic scalpel was used to circumscribe the ovary away from the hilum and then the capsule was incised with scissors, and traction and countertraction were used along with hydrodissection in order to peel the ovarian cyst away from the normal ovarian tissue. There was excellent hemostasis throughout this portion of the procedure.

A small puncture wound occurred about three-fourths of the way through the dissection, and a few droplets of fat escaped, but other than that, there was no evidence of any extrusion of any material.

The cyst was placed in a bag and then removed through the right lower quadrant port piecemeal without contaminating the peritoneal cavity.

The port was replaced. Carbon dioxide was insufflated, and a portion of the ovary was excised to restore normal anatomy. The ovary was then grasped, and 2 separate interrupted #3-0 Vicryl sutures were placed using laparoscopic technique with external knot pusher. There was excellent hemostasis.

Therefore, copious irrigation was undertaken with about 2000 mL of fluid, and all the irrigant was removed. There was no evidence of any contamination with fat or other tissue. The sidewalls were clean and the cul-de-sac was clean. Therefore, Interceed was placed around the hemostatic ovary, tacked down with saline, and then the instruments were removed under direct visualization. The fascial incisions were sewn with #2-0 Vicryl for the right lower quadrant and #2-0 PDS for the umbilical incision, and then staples were used to close the skin edges. Dressings were applied, and the patient was taken from the operating suite after extubation with instrument and sponge counts correct, having tolerated the procedure without complications.

OB-GYN Medical Transcription Operative Sample Report #2

DATE OF OPERATION:  MM/DD/YYYY

OPERATION PERFORMED:  Hysteroscopy, uterine curettage, and endometrial polyp excision.

OPERATIVE FINDINGS:  Normal size anteverted uterus.  No adnexal masses.  Uterine sound 6 cm with a very small polyp at the fundus of the endometrium.  Normal tubal ostia; otherwise, very minimal endometrial tissue.

COMPLICATIONS:  None.

Distention media was used glycine.  Glycine deficit was zero at the end of the procedure. There were no complications.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room and placed in the dorsal supine position.  After induction of general anesthesia, the patient was placed in the dorsal lithotomy position, and the perineum was prepped and draped in the usual sterile fashion.  Examination under anesthesia revealed findings described above.  A speculum was inserted into the vagina.  A sharp-tooth tenaculum was used to grasp the anterior lip of the cervix.  The endocervical canal was then dilated after sounding the uterus to 6 cm.  It was easily dilated to a #20 Hanks dilatation.  A rigid hysteroscope was then inserted, which revealed very thinned out endometrial echo with a very small endometrial fluffy polyp at the fundus of the uterus measuring approximately 2 mm.  We then removed the scope, used the polyp forceps to remove the polyp and curetted the endometrial cavity removing a very minimal amount of tissue.  The scope was inserted at the end of the procedure, which revealed that the polyp had been removed.  Adequate hemostasis was noted.  All instruments were removed from the vagina.  Minimal bleeding from the tenaculum site was controlled with silver nitrate and pressure.  She tolerated the procedure well with no complications and was sent to the recovery room in satisfactory condition.

PREOPERATIVE DIAGNOSIS: Multiple uterine fibroids.

POSTOPERATIVE DIAGNOSIS: Multiple uterine fibroids.

OPERATION PERFORMED:
1. Abdominal myomectomy.
2. Chromopertubation.

SURGEON: John Doe, MD

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 200.

COMPLICATIONS: None.

OPERATIVE FINDINGS: The patient had a uterus that measured about 11 cm in size, grossly normal-appearing tubes and ovaries bilaterally. However, she had multiple uterine fibroids noted, various sizes, the largest being approximately 5 cm in size, located posteriorly in the lower uterine segment, and multiple smaller fibroids on the anterior and posterior surface.

DESCRIPTION OF OPERATION: The patient was taken to the operating room when anesthesia was found to be adequate for the abdominal myomectomy procedure. She was prepared and draped in a normal sterile fashion, in dorsal lithotomy position. A weighted speculum was placed into the patient’s vagina. The anterior lip of the cervix was grasped with an Allis clamp and a Hulka tenaculum was placed into the patient’s cervical os to accommodate the chromopertubation.

Attention was turned to the patient’s abdomen, at which time a Pfannenstiel skin incision was made with a scalpel and carried down to the underlying fascia with a Bovie. This incision was extended laterally using Mayo scissors. The superior and inferior aspects of this incision were grasped with the Kocher clamps, elevated, and the rectus muscles were dissected off. Access was gained to the peritoneal cavity through a separation of the rectus muscles. At that time, a survey of the upper abdomen revealed no gross abnormalities palpated. The pelvis showed an enlarged multiple fibroid uterus. At that time, the bowel was packed away with large moist lap pads. The Kretschmer retractor was placed into the patient’s abdomen to facilitate visualization.

Once there was proper visualization of the uterus, the anterior surface of the uterus was then evaluated and Pitressin was injected along the myoma surfaces. Once the myomas were isolated, they were grasped with the towel clip and between blunt dissection and needle tip Bovie cautery, that was used to be shelled out of the myometrium completely. Once all the anterior fibroids were removed, each remaining surface was closed in three layers using 2-0 Vicryl in a series of figure-of-eight initially, then a running locked layer of another 2-0 Vicryl, and finally 3-0 Vicryl in the serosal layer. This was done all along the anterior surface of the uterus where each myoma was removed.

Attention was then turned to the patient’s posterior uterus, where in a similar fashion multiple smaller fibroids were handled; however, the largest fibroid being about 5 cm located in the lower posterior uterine segment. That one was also injected with Pitressin solution, incised with the needle tip Bovie cautery, double towel clips were used to grasp this fibroid and to dissect it out of the myometrium. This fibroid was also closed in three layers. Hemostasis was ensured throughout each incision site. Once all fibroids were removed, there were a total of 11 fibroids. The pelvis was then irrigated with warm normal saline and again hemostasis was ensured.

All packs and retractors were removed from the patient’s abdomen. She was flattened out of the Trendelenburg position. The fascia was reapproximated using 2-0 Vicryl x2. The subcutaneous tissue was closed using 3-0 Vicryl suture and finally the skin was closed with staples. Sponge, lap, and needle counts were correct x2 and she was taken to the recovery room in stable condition.

PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Dysmenorrhea.
3. Menometrorrhagia.

POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. Dysmenorrhea.
3. Menometrorrhagia.
4. Bilateral hydrosalpinges.

OPERATION PERFORMED: Laparoscopic subtotal hysterectomy with bilateral salpingectomies.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

IV FLUIDS: Crystalloids.

ESTIMATED BLOOD LOSS: 50 mL.

URINE OUTPUT: 500 mL with clear urine.

INDICATIONS FOR OPERATION: The patient strongly desired removal of the uterus due to symptoms delineated in her history and physical. There were no contraindications for the planned procedure. The risks, benefits, and alternative were discussed again with the patient and her family prior to commencing the surgery, and informed consent was obtained.

INTRAOPERATIVE FINDINGS: Uterus, 14 to 16 weeks’ size, quite boggy, and without adnexal masses or perineal, vaginal or perianal abnormalities. No cervical induration. The cervix was mobile. Intraoperative findings included an unremarkable-appearing liver edge, anterior abdominal wall, bilateral round ligament insertions, bilateral ovaries, bilateral uterosacral ligaments, bilateral ureters, retrocervical area, cul-de-sac, pelvic sidewalls, vesicouterine fold, and enlarged uterine fundus consistent with a 14 to 16 weeks’ size uterus. The right and left fallopian tubes were enlarged with evidence of bilateral hydrosalpinges with no evidence of malignancy. The ovaries were grossly normal. There was excellent hemostasis. The uterus was seen prior to, during, and after the procedure. There was normal peristalsis without evidence of hydroureter or other abnormalities. There was no evidence of trauma to the intestines, ureter or bladder.

DESCRIPTION OF OPERATION: After appropriate informed consent was obtained, the patient was taken to the operating suite, given general endotracheal anesthesia, and prepped and draped in the usual sterile fashion in the dorsal lithotomy position with a Foley catheter in place. A wet laparotomy pack and a single-tooth tenaculum were used to grasp the cervix and to retain pneumoperitoneum. A 5 mm infraumbilical incision was made and then later 5 mm left to right lower quadrant incisions were made. An optical trocar was placed under direct visualization into the peritoneal cavity angled toward the pelvis without trauma to underlying organs. Carbon dioxide was insufflated in the left and right lower quadrant. Trocars were placed under direct visualization.

The round ligaments, utero-ovarian ligaments, and broad ligament tissue immediately adjacent to the uterus were taken with the Harmonic scalpel with excellent hemostasis. The ureters were visualized during the entire procedure. After skeletonization was performed, the vesicouterine fold was developed anteriorly, and some adhesions were noted to the cervix. These were released with careful dissection. A clear plane was identified, and the bladder was brought down onto the cervix.

The patient’s cervix was fairly large. The uterine vessels were skeletonized, were identified, and were taken with the Harmonic scalpel using a triple-cautery technique. The tissue was then removed along the cardinal ligaments immediately adjacent to the cervix in order to perform a supracervical hysterectomy. A supracervical hysterectomy was performed by circumscribing the cervix using the Harmonic scalpel. Wall of the bowel and sidewalls were visualized.

The specimen was removed as was the right fallopian tube, but the left fallopian tube was taken so that it was a part of the specimen. The ovaries were grossly normal. There was excellent hemostasis. The ureters were visualized. Therefore, morcellation was undertaken by using the Gynecare morcellator immediately adjacent to the intra-abdominal wall and well away from the bowel. The blade was retracted when the specimen was being removed from the body.

All specimens, including the right fallopian tube, were taken uneventfully and sent for permanent pathologic evaluation. The pressure was dropped. Hemostasis was assured. Copious irrigation was undertaken and two separate 0-Vicryl sutures were used to close the anterior and posterior cervical tissue across the remaining endocervical tissue. The endocervical tissue just prior to this was cauterized with the bipolar cautery. A piece of SurgiWrap was placed in the pelvis and covered the cervix completely. Pressure was dropped. Hemostasis was assured and then the Carter-Thomason device was used along with a 0-Vicryl suture to close the right lower quadrant trocar site. There was an air-tight seal; therefore, the instruments were removed under direct visualization.

The carbon dioxide was released, and the incisions were sewn with running subcuticular 4-0 Vicryl sutures. Steri-Strips were applied. The catheter was removed draining clear urine, without any blood, and the patient was extubated and taken from the operating suite having tolerated the procedure without complications and with sponge and instrument counts correct.

POSTOPERATIVE DIAGNOSES:
1. Endometrial hyperplasia.
2. History of breast cancer.
3. Fibroid uterus.

OPERATION PERFORMED: TAHBSO.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

EBL: 100.

URINE OUTPUT: 300 mL, clear urine.

FLUIDS: At the end of the procedure, 1500 mL crystalloid.

FINDINGS: Exam under anesthesia was not performed.

OPERATIVE FINDINGS: Approximately 8-week size uterus with normal tubes and ovaries bilaterally. Normal-appearing cervix. Uterus had a small right lower segment approximately 3 cm submucosal fibroid.

SPECIMEN: Sent to pathology.

DESCRIPTION OF OPERATION: The risks, benefits, indications, and alternatives to the procedure, TAHBSO, were reviewed with the patient in detail, and informed consent was obtained for the TAHBSO. The patient was taken to the operating room and placed in the supine position. She was given general endotracheal anesthesia and prepped and draped in the normal sterile fashion.

A Pfannenstiel incision was made and carried out to the underlying layer of fascia, which was incised bilaterally and extended with curved Mayo scissors. Muscles were separated in the midline, and peritoneum was entered bluntly and was extended. The pelvis was examined and the findings were noted above. An O’Connor-O’Sullivan retractor was placed into the incision. Bowel was packed away with moist laparotomy. Two Kelly clamps were placed on the cornua, used for retraction. The round ligaments on the right side were clamped, transected, and suture ligated with 0 Vicryl. The anterior leaf of the broad ligament was incised along the bladder reflection, and the bladder was dissected off with a sponge stick. Infundibular ligaments on the right side were then doubly clamped, transected, and suture ligated behind the ovary. This was then done on the patient’s left side. Hemostasis was obtained bilaterally. The uterine arteries were then skeletonized bilaterally, clamped with Heaney clamps, transected, and suture ligated with 0 Vicryl. Hemostasis was assured.

Uterosacral ligaments were then clamped on both sides, transected, and suture ligated in a similar fashion. The cervix and uterus were then amputated using scissors. Vaginal cuff angles were closed and transfixed to the lateral cardinal and uterosacral ligaments. The remainder of the vaginal cuff was then closed with a series of interrupted figure-of-eight sutures with 0 Vicryl. Hemostasis was obtained. The pelvis was irrigated copiously with warm normal saline. Laparotomy sponges and instruments were removed from the abdomen. The fascia was closed with running 0 Vicryl. Hemostasis was obtained. The skin was closed with staples. Sponge, lap, and needle counts were correct x2. The patient was taken to the PACU in stable condition.

POSTOPERATIVE DIAGNOSIS: Pelvic organ prolapse.

OPERATIONS PERFORMED:
1.  Abdominal sacral colpopexy.
2.  Anterior repair.
3.  Posterior repair.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

OPERATIVE FINDINGS:  Omental adhesions to the anterior abdominal wall, large bowel adhesion to vaginal cuff, grade 2 vaginal vault prolapse, grade 3 cystocele, grade 2 rectocele.

SPECIMENS:  None.

TUBES:  Foley.

URINE OUTPUT:  325 mL.

ESTIMATED BLOOD LOSS:  75 mL.

COMPLICATIONS:  None.

POSTOPERATIVE CONDITION:  Good in PACU.

DESCRIPTION OF OPERATION:  The patient was taken to the operating room where general endotracheal anesthesia was induced for abdominal sacral colpopexy, anterior repair, and posterior repair. The patient was prepped and draped in the normal sterile fashion. The patient was placed in Allen stirrups. A midline incision was then made with the help of a scalpel. The incision was taken down to the rectus fascia, which was incised in the midline sharply. Subsequently, the rectus muscle was separated in the midline, and the peritoneal cavity was entered sharply. It was noted that there were omental adhesions down to abdominal wall. These were taken down with Metzenbaum scissors and the Bovie.

Subsequently, on further inspection, there was a large bowel adhesion to the vaginal cuff, and EEA sizer was placed in the vagina for visualization of the vaginal vault. The adhesion was then taken down with the help of Metzenbaum scissors. Subsequently, the bowel was packed. A Balfour retractor was placed and the sacrum was identified. The peritoneum over the sacrum was then incised to expose the longitudinal sacral ligament.

Subsequently, a 0 Ethibond suture was placed through the longitudinal sacral ligament. Hemostasis was then assured over the sacral promontory. Subsequently, the two ends of the Ethibond sutures were placed through a Gore-Tex mesh, and the suture was tied down to the sacrum, thus anchoring the mesh. Subsequently, two sutures of 0 Ethibond were placed laterally to the vaginal cuff, and those sutures were then passed through the Gore-Tex mesh so that the Gore-Tex mesh was attached to the vaginal vault. This was done on both sides.

Subsequently, a third suture was placed in the midline over the vaginal vault. Hemostasis was noted. At this point, the sponges, laps and retractor were removed, and the fascia was closed with 0 PDS suture. The subcutaneous tissue was approximated with 2-0 Vicryl suture, and the skin was closed with staples.

Attention was then turned to the anterior and posterior repair part of the procedure. It was noted at this point that the grade 3 cystocele was reduced to a grade 2 cystocele. Thus, an incision was made in the anterior vaginal mucosa. The incision was taken down to just below the mid urethral position since the patient had a previous TVT and there was concern about disrupting the previous TVT. The bladder was dissected off the anterior vaginal mucosa bilaterally. The pubovesical fascia was approximated in the midline with 0 Vicryl suture. Three such sutures were placed. Subsequently, the excess vaginal skin was trimmed, and the vaginal wall was closed with interrupted 2-0 Vicryl sutures.

Attention was then turned to the posterior repair part of the procedure. Two Allis clamps were placed at the introitus. An incision was then made between the two Allis clamps, and with the help of the Metzenbaum scissors, the posterior vaginal walls were separated from the rectum up to midway in the vagina. The rectovaginal fascia was separated from the vaginal mucosa on both sides. The rectovaginal fascia was approximated in the midline with 0 Vicryl sutures. Four such sutures were placed. The excess vaginal skin was removed, and the vaginal skin was approximated with 2-0 interrupted sutures. At the introitus, a running suture of 3-0 Vicryl was placed and closed in a subcutaneous fashion.

At the end of the procedure, the Foley catheter was placed, and the vagina was packed. Sponge and needle counts were correct. The patient tolerated the procedure well.

POSTOPERATIVE DIAGNOSIS: Left recurrent Bartholin’s cyst with abscess formation.

PROCEDURE PERFORMED: Marsupialization of left Bartholin’s cyst.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Negligible.

INDICATIONS FOR PROCEDURE: The patient was brought to the operating room for treatment of recurrent left Bartholin’s cyst. The patient is (XX) years of age. She has had a history of multiple problems related to previous bartholinitis and Bartholin’s abscess and cyst formation. The patient had an initial episode of a Bartholin gland infection with abscess formation treated with incision and drainage. She was asymptomatic. She had a recurrent left Bartholin’s cyst and was treated with Word catheter placement. She developed a recurrent painful enlarging gland. After careful discussion of all alternatives and risks and benefits, marsupialization was recommended and the procedure planned. The patient was admitted for the procedure.

ANATOMICAL FINDINGS: At the time of surgery, a left Bartholin’s duct cyst was present, measuring approximately 4 x 4 cm in size. The site of the previous Word catheter placement was totally occluded. This occlusion was complete with scarring. On incising the gland, the cyst contents were filled with purulent material and a large volume of chocolate, old blood consistent with previous bleeding into the gland. Some hemosiderin deposits were noted involving the lining of the gland.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and given adequate general anesthesia. She was examined confirming the presence of the Bartholin’s cyst. The bimanual examination was unremarkable. There were no other vulvar lesions. She was then prepped and draped in the usual manner.

The cyst was outlined and noted. Sterile gauze was placed in the vagina to prevent any contamination. The large cyst was then incised outside of the hymenal ring on the vaginal mucosa. Cultures were obtained. The incision was then enlarged to approximately 3.5 cm, and the purulent chocolate drainage was noted. The cyst was then liberally irrigated with the use of an Asepto syringe and normal saline. There were no loculations. Minor inflammatory changes were noted involving the cyst wall. A biopsy of the cyst wall was obtained and sent to pathology.

At this time, the elliptical incision was then sutured in the classical fashion, suturing the mucosal lining of the cyst to the skin with interrupted 3-0 Vicryl suture at strategic intervals approximately 0.5 cm apart. Good hemostasis was achieved. The cyst was further irrigated with the use of normal saline. Good hemostasis was present, and no further procedures were performed. All instruments were removed. All gauze packing was removed from the vagina and the vagina irrigated. No further procedures were performed. The patient was stable at all times. The patient was returned to the Same Day Surgical Unit in stable and satisfactory condition.

In summary, the following procedures were performed: Marsupialization of left Bartholin cyst and biopsy of Bartholin cyst wall.

POSTOPERATIVE DIAGNOSES:
1.  Postdates intrauterine pregnancy.
2.  Failure to progress in labor.
3.  Failed induction of labor.
4.  Fetal macrosomia.

PROCEDURE PERFORMED:  Primary low transverse cesarean section.

SURGEON:  John Doe, MD

ANESTHESIA:  Spinal.

ESTIMATED BLOOD LOSS:  600 mL.

COMPLICATIONS:  None.

DISPOSITION:  The patient was taken to the recovery room in good condition at the termination of the procedure.

DESCRIPTION OF PROCEDURE:  The patient is a (XX)-year-old gravida 1, para 0, EDC is MM/DD/YYYY. She was admitted with complaints of decreased fetal movement. A biophysical profile returned with a score of 6 out of 8. The decision was made to proceed with an induction of labor. The risks and benefits were explained as well as the patient’s alternatives.

A Cervidil induction of labor was started. The afternoon of MM/DD/YYYY, the patient was having contractions and her membranes were ruptured. She was approximately 2 cm dilated and 80% effaced at a -2 station at 1 p.m. on MM/DD/YYYY. Pitocin was given with very careful labor monitoring. The afternoon of MM/DD/YYYY, an internal uterine monitor was placed to allow for careful monitoring of her labor. She was reassessed at 11 p.m., and at that time, the patient was 4 cm dilated, 80% effaced and at a -2 station. Despite excellent contractions, there was virtually no change in the cervix and no descent over the head over the several previous hours. The decision was made to proceed with a cesarean section. This was discussed with the patient and her husband.

The patient was taken to the operating room where spinal anesthesia was administered without complication. She was placed in the supine position with lateral displacement of the uterus. She was prepped and draped in the usual fashion. A Pfannenstiel skin incision was performed and carried down to the fascial layer. The fascia was transected, the rectus muscles were retracted laterally. The peritoneum was entered under direct visualization. The bladder was dissected off the lower uterine segment. A low transverse uterine incision was performed with a scalpel and carried laterally with curved scissors. A 9 pound 7 ounce healthy male infant was delivered and handed to the neonatal nurse in attendance. Cord bloods were obtained, and the placenta was extracted and the uterus delivered into the operative field for repair.

The uterine incision was repaired in two layers using 0 chromic sutures. The incision was hemostatic. The bladder flap was reapproximated with a running stitch of 3-0 Vicryl suture. The uterus, tubes, and ovaries all appeared normal. The uterus was placed back into the abdominal cavity. The abdominal cavity was cleaned of any remaining blood and amniotic fluid. The sponge, needle, and instrument counts were correct. The parietal peritoneum was reapproximated with interrupted 2-0 Vicryl suture. The rectus muscles were reapproximated with interrupted 0 Vicryl suture. The fascia was closed with 0 PDS suture. The subcutaneous tissue was reapproximated with interrupted 3-0 Vicryl suture. The skin was closed with a running subcuticular stitch of 4-0 Vicryl suture. A dry sterile dressing was placed over the incision. The patient was then transferred to the recovery room in good condition.

POSTOPERATIVE DIAGNOSIS: Right ovarian fibroma.

OPERATION PERFORMED: Bilateral salpingo-oophorectomy.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: Minimal.

CONDITION: Stable to the recovery room.

DRAINS: Foley to gravity.

COMPLICATIONS: None.

SPECIMENS: Right tube and ovary (frozen section), left tube and ovary.

INDICATIONS FOR OPERATION: This (XX)-year-old woman was referred with a solid mass of the right ovary. She is status post transvaginal hysterectomy for benign disease.

DESCRIPTION OF OPERATION: After an adequate level of general endotracheal anesthesia was obtained, bimanual rectovaginal exam was performed revealing a right ovary that seems to be adherent to the right pelvic sidewall. The left adnexa are not appreciated as abnormal. The patient was prepped and draped for an abdominal procedure.

A midline vertical incision was made in the skin and extended from the symphysis pubis to the umbilicus. Subcutaneous fat and fascia were divided. Underlying peritoneum was entered. A small amount of fluid was aspirated and submitted for cytologic study. A Bookwalter retractor was placed into the operative field. The right ovary was elevated up out of the pelvis, where it had some filmy adhesions adhering it to the right pelvic sidewall. The surface overall was smooth. It was a very hard mass measuring approximately 10 x 8 x 9 cm. It also had undergone torsion x3 with clot appreciated in the vessels of the infundibulopelvic ligaments, which were markedly tortuous and varicosed.

The right ureter was identified. The right infundibulopelvic ligament and meso-ovarian ligaments were clamped across in a series of steps with the LigaSure. The tissue was coagulated and divided. This specimen was passed to Pathology for assessment. In the meantime, the left ovary, which was atrophic and normal in appearance, was elevated, and the meso-ovarian ligament and infundibulopelvic ligament were both clamped across after identification of the course of the left ureter. This pedicle was coagulated and divided and submitted for pathology permanent sections. After there was a confirmation of the right ovary being a fibroma, the pelvis was irrigated. No bleeders were identified. The lap pads were removed. The intestines were allowed to return to the normally occurring location.

The abdomen was closed with looped 0 PDS on the fascia. The subcutaneous tissues were irrigated and reapproximated with 3-0 Vicryl. The skin edges were reapproximated with staple. Sponge, needle, and instrument counts were reported as correct, and the patient was transferred to the recovery room in stable condition.

PRE-PROCEDURE DIAGNOSIS: A (XX)-year-old gravida 3, para 1-1-0-1 with history of previous cesarean section, declined vaginal birth after cesarean section, and undesired fertility.

POST-PROCEDURE DIAGNOSIS: A (XX)-year-old gravida 3, para 1-1-0-1 with history of previous cesarean section, declined vaginal birth after cesarean section, and undesired fertility.

PROCEDURE PERFORMED: Cesarean section and Parkland tubal ligation.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: Approximately 350 mL.

FINDINGS: Female infant born weighing 8 pounds with Apgars of 9 and 9.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and given general endotracheal anesthesia, and anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion.

An elliptical incision was made over the previous keloid scar and removed. A Bovie was used to transect the subcutaneous tissue to the fascia, which was dissected laterally with curved Mayo scissors. The Kocher clamps were used to grasp the superior and inferior portions of the fascial incisions and subsequently dissected off with a Bovie and bluntly. The rectus abdominal muscles were divided in the midline.

The Alexis O cesarean retractor was placed in the incision. The vesicouterine peritoneum was identified, transected, creating the bladder flap. A scalpel was used to make a transverse incision in the low uterine segment and extended laterally with the bandage scissors. The head was delivered atraumatically. Mouth and nares were suctioned at the incision. The posterior shoulder was delivered followed by the anterior shoulder and entire body. The cord was clamped twice and cut in between. The infant was handed off to the awaiting pediatrician. The placental delivery was spontaneously intact 3-vessel cord. Twenty units of Pitocin in 1 liter of LR was given after placental delivery. The hysterotomy was repaired with 0 chromic in a running locked fashion. Hemostasis was assured.

Attention was turned to the right fallopian tube, which was carried to the fimbriated end. A window was created in mesosalpinx and 0 plain gut was used to create the Parkland tubal ligation. In similar fashion, the left fallopian tube was identified, carried to the fimbriated end. A window was created in the mesosalpinx. The 3-0 plain gut was used to create a Parkland tubal ligation. Hemostasis was assured.

The pelvis was copiously irrigated with warm normal saline. Interceed was placed on the hysterotomy repair. The rectus abdominal muscles were reapproximated in midline with 2-0 chromic in a U-stitch. The fascia was reapproximated with 0 Vicryl in a running fashion. The skin was closed with staples. The patient tolerated the procedure and was taken to the recovery room in stable condition.

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Multiparity, desires permanent sterilization.

POSTOPERATIVE DIAGNOSIS: Multiparity, desires permanent sterilization.

PROCEDURE PERFORMED: Laparoscopic tubal ligation with Filshie clips.

SURGEON: John Doe, MD

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 100 mL.

IV FLUIDS: 800 mL.

COMPLICATIONS: None.

DISPOSITION: The patient taken to the recovery room in stable condition.

PROCEDURE FINDINGS: Normal uterus, tubes and ovaries bilaterally with Filshie clips placed on midportion of fallopian tubes.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where her general anesthesia was found to be adequate. She was prepped and draped in the normal sterile fashion in the dorsal lithotomy position. The bladder was emptied prior to the procedure. The cervix was grasped with a single-tooth tenaculum. Hulka dilator was placed in the uterus for uterine manipulation.

A 5 mm infraumbilical incision was made with the scalpel. Veress needle was entered into the abdominal cavity. Saline was withdrawn and infused without difficulty, and low pressures were noted upon insufflation. A pneumoperitoneum was created. The 5 mm trocar was entered into the abdominal cavity. The patient was placed in Trendelenburg.

An 8 mm suprapubic incision was made 3 cm above the pubic bone, and the 8 mm trocar was entered into the abdominal cavity without difficulty. A blunt probe was used. The ovaries, tubes and uterus were visualized and felt to be normal. The tubes were followed out to the fimbria.

A Filshie clip was placed on the right midportion of the fallopian tube without difficulty, and a Filshie clip was placed on the left midportion of the fallopian tube without difficulty. Decision was made to end the procedure. The 8 mm trocar was removed under direct visualization. The pneumoperitoneum was released. The 5 mm trocar was removed.

The incisions were closed with 4-0 Monocryl. Mastisol and Steri-Strips were placed. The Hulka dilator was removed and Monsel was placed. The patient tolerated the procedure well. All sponge, lap and needle counts were correct x2.