Operative Report Example 4

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Operative Report

Service: Surgery
Sex: Female
Age: 62
Race: Black
Date: 01/15/91

Surgeon: Z. Alterman, MD
Assistant: R. Hand, MD
Anesthesiologist: Bo Peep, MD

Name of Operation: Abd. Expl.-Distal gastrectomy-Gastroduodenostomy

Anesthesia: General

Pre-operative Diagnosis: Carcinoma of the stomach

Post-operative Diagnosis: Carcinoma of the stomach with metastasis to liver

Operation Started: 11:15 am
Operation Ended: 1:55 pm

Patient Name: Ann Trum
Record Number: 000035

Clinical History:

This 62 year-old black female had been worked up by medicine for masses in the epigastrium. A liver scan revealed multiple filling defects and an upper GI series revealed an antral lesion which was obstructing the fundus of the stomach.

Operative Findings:

Under general anesthesia, with the patient in the supine position, the abdomen was prepped and draped in the usual fashion. An upper midline incision was made and the peritoneal cavity entered. Generalized abdominal exploration revealed multiple large nodules within the substance of both lobes of the liver and a large ulcerating lesion in area of the antrum of the stomach. Multiple nodes along the lesser and greater curvature of the stomach and the subpyloric area were positive clinically for tumor. The stomach was not adherent to the pancreas or any other structures, therefore, a distal gastrectomy was undertaken. The greater and lesser curvatures of the stomach were freed up as was the duodenum, and Payr clamps were placed along the distal stomach just beyond the pylorus, and the distal stump was amputated.

Procedure Continued:

This was reflected up and the left gastric arteries were ligated. The stomach was then transected in the usual fashion and the greater curvature tapered using a 2-0 chromic and an inverting suture of 2-0 silk. The distal lumen was free of tumor and this was then anastomosed in 2-layer fashion to the proximal duodenum using an inner running suture of 3-0 chromic and an outer interrupted of 3-0 silk. Estimated blood loss during the procedure was approximately 300 cc's. The sponge counts at the conclusion of the procedure were correct.

The abdomen was closed with nylon retentions and midline sutures of zero-silk. The skin was closed with interrupted 4-0 silk. The patient tolerated the procedure well, however, a period of Cheyne-Stokes respiration followed the conclusion of the case and the endotracheal tube was allowed to remain in, and the patient was placed on a Byrd Respirator in the recovery room. Other than this, the case went smoothly and the patient did well.

Surgeon: Z. Alterman, MD
Date: 01/15/91

Date dictated: 01/15/91
Date transcribed: 01/18/91

Patient Name: Ann Trum
Record Number: 000035