Orchiectomy Procedure Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Dog bite to scrotum.

POSTOPERATIVE DIAGNOSIS:  Dog bite to scrotum.

OPERATION PERFORMED:
1.  Scrotal exploration.
2.  Left orchiectomy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General.

DRAINS:  Penrose drain from the scrotum.

TRANSFUSIONS:  None.

ESTIMATED BLOOD LOSS:  5 mL.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old Hispanic male who presented to the ER with a dog bite to the scrotum. The decision was made to bring the patient to the operating room for exploration and possible left orchiectomy as indicated.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. After induction of general anesthesia, the patient’s perineum and genitalia were sterilely prepped and draped in the standard fashion. The scrotum was examined, and there was significant injury to the left testicle and its blood supply. The decision was made to perform a left orchiectomy.

The spermatic cord was isolated from the surrounding structures. It was clamped with two Kellys, and Metzenbaum scissors were used to cut the left testis free between the clamps. The specimen was handed off the table and sent to pathology as a specimen. A 3-0 Vicryl suture was used to tie the cut end of the spermatic cord. This was repeated times one. The exit wound was cleaned using the pulse evacuator. The patient also was noted to have a more superficial wound on the right hemiscrotum; one on his anterior right thigh and one on his penile shaft. All of these wounds were cleaned well with the pulse evacuator.

Next, the wound was inspected for hemostasis. A 3-0 Vicryl suture was then used to reapproximate the Dartos layer with simple interrupted sutures. The skin edges were then loosely reapproximated with vertical mattress sutures with 2-0 chromic. The smaller wounds were closed with simple interrupted sutures using chromic, then right thigh wound was closed using staples. Prior to wound closure, a Penrose drain was placed and was sutured to the skin in the scrotum. The patient did receive preoperative antibiotics. The patient was awakened from anesthesia and was transferred to the postanesthesia care unit in stable condition.