Answer: Operative Report Example 3

12/15/91 Expl. Laparotomy:

Ligation of (R) ureter to control bleeding; removal of tumor impossible because of size and probable fixation to the diaphragm and the great vessels. Dx: Carcinoma of (R) kidney.

Answers to Questions:

  1. No. This condition was discovered as part of the pre-operative evaluation.
  2. No. This observation is not directly related to the malignancy.
  3. Yes. The operative record contains information regarding why the tumor was not removed. This is useful information and should be recorded. This operation was performed to correct another condition secondary to the malignant condition (the ureter was tied to cause blood to back up and clot, thus, preventing further bleeding). This report is also of interest because it describes the extent of the disease.
  4. No. There is no mention of removal of tissue.
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