Operative Report Example 2

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Operative Report

Service: Surgery
Ward: W-405
Sex: Male
Age: 74
Race: Black
Date: 03/11/91

Surgeon: Abel Cutter, MD
Assistant: Stan McWait, MD
Anesthetist: A. Snooz, RN

Name of Operation:Exploratory Laparotomy

Pre-Operative Diagnosis: Carcinoma of the Stomach

Post-Operative Diagnosis: Carcinoma of the Stomach

Operation Started: 7:05 am
Operation Ended: 8:40 am

Operative Findings

Clinical History:

This 74 year-old black male was admitted to the General Surgery Service for a thorough G.I. work-up carried out because of a history of 60 lb. weight loss during the past eight months. GI series demonstrated a large space-occupying lesion in the fundus of the stomach. Chest films, liver scan, and further diagnostic studies did not indicate metastatic spread. Therefore, it was elected to explore this patient; on 03/11/91, he was taken to the operating room.

Procedure in Detail:

Under adequate endotracheal anesthesia, the abdomen was prepped with pHisoHex and Betadine and draped for an upper midline incision. A small upper midline incision was made to explore the abdomen. The peritoneum was entered. Manual exploration demonstrated a large, hard, fixed mass on the posterior wall of the fundus of the stomach. There were some tumor studdings in the left lobe of the liver. A node was selected for biopsy, and a small wedge of this node was removed. The midline was then closed with interrupted figure-eight sutures of 0-stainless steel wire; retention sutures were utilized to close the same. The skin was closed with 3-0 black silk and no blood was administered during the surgical procedure. The patient tolerated the procedure well.

Date Dictated: 03/11/91
Date Transcribed: 03/13/91

Patient Name: Whatt U. Eton
Record Number: 000033