EXAMPLE
Taki Anagnoston, M.D.
OPERATIVE REPORT
________________________________
PEDIATRICIAN: Mazhar Khan, M.D.
ANESTHESIOLOGIST: Amitabh Mathur, M.D.
ANESTHESIA: Spinal.
PREOPERATIVE DIAGNOSES:
1.
Term uterine pregnancy.
2.
History of a previous cesarean section.
POSTOPERATIVE DIAGNOSES:
1.
Term uterine pregnancy.
2.
History of a previous cesarean section.
OPERATION: Repeat transverse anterior cervical cesarean section.
PROCEDURE: The patient was prepared and draped in the supine
position for abdominal surgery procedure. Through a Pfannenstiel
incision, removing the old surgical scar, the peritoneal cavity
was entered without difficulty. Examination of the abdomen
revealed no gross pathology. Examination of the pelvis revealed a
term pregnant dextrorotated uterus containing an active fetus in
unengaged vertex position. Both fallopian tubes and ovaries were
normal in size, shape, appearance, and location on the uterine
fundus. The peritoneum overlying the lower anterior corpus was
incised transversely and the underlying urinary bladder separated
off the uterus and retracted inferiorly and laterally, well away
from the operative field. The urinary bladder was distended with
methylene blue tinted saline before dissection, and after
dissection the bladder was drained and then retracted. Through
the thinned-out anterior cervical segment, a transverse incision
was made and the fetal head was easily delivered manually with
the aid of fundal. The rest of the fetus was delivered without
problems. The baby was quickly suctioned and the cord clamped
and cut, and the baby was handed to Dr. Khan for further
resuscitation.
Aerobic and anaerobic cultures were taken from the uterine cavity
and the placenta, and the placenta was delivered manually.
Intravenous Pitocin and intramuscular Methergine were given to
promote and maintain uterine contraction, followed by
prophylactic 2 grams of Cefotan intravenous antibiotic. The
uterine cavity was irrigated with warm water and the uterine
incision closed in one layer of running locked #1 chromic catgut
suture. The uterine incision was reinforced with several
interrupted figure-of-eight #1 chromic catgut sutures. All free
blood from the pelvis was removed and the pelvis was irrigated
with warm water. Examination of the pelvis showed good
hemostasis.
There being no further problems, the Pfannenstiel incision was
closed by approximating the parietoperitoneum with a running 3-0
Vicryl suture. The rectus muscles approximated with a running 3-0
Vicryl suture. The deep fascia approximated with a running locked
1 PDS suture. The subcutaneous tissue was approximated with a
running 3-0 plain catgut suture and the skin edges were
approximated with a subcuticular 4-0 Vicryl suture. A dry
sterile dressing was placed on the incision. The patient returned
to the recovery room in excellent condition.
ESTIMATED BLOOD LOSS: 600 mL.
BLOOD REPLACED: None.
PACKS AND DRAINS: #16 Foley catheter in the urinary bladder
connected to floor drainage.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: The patient is good.