Exploratory Surgery & Operative Report
Sometimes, cancer of an internal organ may be suspected but the organ may be so located that direct access to it is possible only with surgery. Exploratory surgery may then be performed to determine whether or not a cancerous condition exists and the degree to which the cancer may have affected other organs and structures within the observed area. In most instances, biopsies will be performed and the specimen examined histologically. The exploratory operation may be followed immediately by definitive surgery, or it may reveal cancer so extensive as to rule out definitive surgery. It may be that [glossary term:] by-pass surgery is indicated as a palliative measure. All surgery, whether it is definitive, exploratory, or by-pass surgery, is described in an operative report.
An operative report will usually contain a pre- and post-operative diagnosis, the name of the procedure, and the operative findings. The findings may include statements as to the exact location of the primary tumor, the size of that tumor, and the extent to which it has or has not spread beyond the primary site. Therefore, close scrutiny of the entire operative report is required. What the surgeon sees is significant, especially if all of the malignancy is not excised or if no definitive surgery is done. This may be the most complete description of the malignancy available, and it should be abstracted.