Operative Report Example 1

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Operative Report

Service: Gen.
Name:Hugh Gutzman
Hosp. No.: 000032

Sex: Male
Age: 87
Race: White
Date: 9/27/91

Surgeon: Polk N. See, MD
Assistant: A. Helpp, MD
Anesthetist: Al Quiet, MD

Name of Operation: Exploratory Laparotomy

Pre-Operative Diagnosis: Bleeding Stomach Cancer

Post-Operative Diagnosis: Inoperable Stomach Cancer

Operation Started: 11:52 am

Operative Procedure: Exploratory Laparotomy

Procedure in Detail:

With the patient supine and under endotracheal anesthesia, the entire abdomen and lower chest was prepped with pHisoHex and saline and draped with sterile sheets in the usual manner. Through an upper midline incision the peritoneal cavity was entered. Exploration revealed a huge mass posterior to the 7th rib which was penetrating the stomach, apparently causing the bleeding. This mass measured about 7 inches in diameter. It was fixed in the retroperitoneal space and to the posterior part of the stomach. It also ascended into the liver, and there were multiple liver metastases and multiple peritoneal metastases. A node from the greater omentum was biopsied; frozen section reported a highly anaplastic malignancy. The patient was inoperable. Through the gastrohepatic ligament the mass was further exposed and two sutures of 2-0 chromic were placed in the mass, and a small wedge biopsy was performed. The tumor was bleeding, and sever sutures of 2-0 chromic atraumatic and a piece of Surgicel was inserted; the bleeding was controlled. The patient was poorly prepared pre-operatively, and his condition has not changed.

Dictated: 09/27/91
Date transcribed:10/01/91