Answer: Operative Report Example 1

09/27/91 Expl. Lap.:

Huge mass posterior to 7th rib penetrating stomach, 7 in. in diameter, fixed in retroperitoneal space and to posterior stomach, ascending into liver with multiple liver and peritoneal metastases. Node from the greater omentum was biopsied (frozen section reported as highly anaplastic and malignant). Wedge Bx of mass. Post-op Dx: Inoperable Carcinoma of stomach.

Comment:

The following points should be noted with respect to the above summary:

  1. Emphasis is placed on summarizing various locations of tumor to indicate the extent of the disease.
  2. Operative procedures are not summarized, but the name of the procedure is recorded, i.e., exploratory laparotomy.
  3. Size of lesion or mass is recorded, if given.
  4. Note that frozen section of biopsied node from greater omentum indicated a highly anaplastic malignancy.
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