Operative Report Example 3

For this example, please answer the following questions:

  1. Were "bilateral pulmonary metastases" observed at the time of surgery?
  2. Do you need to report the observation of "ureter markedly dilated and had bluish appearance?"
  3. Should any of the findings described on this report be reported?
  4. Would you expect a post-operative pathology report to accompany this operative record?

View the suggested abstraction.

Operative Report

Service: GU
Ward ____
Sex: Female
Age: 61
Race: Black
Date: 12/15/91

Surgeon: A. Tieoff, MD
Assistant: A. Sist, MD
Anesthesiologist: Q. Tee, MD

Name of Operation: Exploratory lap with ligation of R ureter

Pre-Operative Diagnosis: Adenocarcinoma R kidney with hematuria

Post-Operative Diagnosis: Adenocarcinoma R kidney with severe hemorrhage

Operation Started: 11:15 am
Operation Ended: 11:42 am

Clinical History:

This 61 year-old black female was admitted to Urology with severe bladder hemorrhage. Physical examination revealed a right flank mass. On IVP the patient had poor to no function. At cystoscopy the patient had a large dilated orifice on the right side with blood gushing through. The patient required 5 units of blood to replace blood loss prior to this (her hematocrit was only 21%). Also pre-operative evaluation revealed the patient had what appeared to be bilateral pulmonary metastases from a hypernephroma and possible metastasis to the right hip. Because of the patient's blood requirements, it was felt that ligation of the ureter might help to control the bleeding.

Operative Findings:

Removal of the tumor was impossible because of its size with probable fixation to the diaphragm and great vessels.

Procedure in Detail:

The patient was placed in the supine position, the sandbag was placed under the right flank, the skin was prepped in the usual manner and sterile drapes were applied in the usual manner. A transverse incision was made extending from the lateral border of the rectus muscle to the anterior superior iliac spine with the combination of sharp and blunt dissection. The muscles were divided, split, and the retroperitoneal space opened at the anterior-superior iliac spine level. The bowel was retracted posteriorly.

The peritoneum was not opened and the ureter was identified as it crossed the pelvic brim. It was markedly dilated and had a bluish appearance. The ureter was ligated with zero-silk at 2 levels.

The patient tolerated the procedure well. A small drain was left in the area of dissection. The muscles were approximated with interrupted zero-chromic, the subcutaneous tissue with 2-0 plain, and the skin was closed with 3-0 silk.

Date dictated: 12/15/91
Date transcribed: 12/16/91

Patient Name: Tessie Sicksack
Record Number: 000034