Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Ligation - Postpartum
Description: Postpartum tubal ligation and removal of upper abdominal skin wall mass.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: Multiparity requested sterilization and upper abdominal wall skin mass.
POSTOPERATIVE DIAGNOSES: Multiparity requested sterilization and upper abdominal wall skin mass.
OPERATION PERFORMED: Postpartum tubal ligation and removal of upper abdominal skin wall mass.
ESTIMATED BLOOD LOSS: Less than 5 mL.
INDICATION: This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007. The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.
PROCEDURE IN DETAIL: The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department. The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation. Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision. The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed. The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection. Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end. A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized. Adequate hemostasis was noted. This tube was placed back in its anatomic position. The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position. The peritoneum as well as fascia was reapproximated with 0-Vicryl. The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch. Pressure dressings were applied. Marcaine 10 mL was used prior to making an incision. Sterile dressing was applied. The large mole-like lesion was grasped with Allis. It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied. Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.
Keywords: obstetrics / gynecology, sterilization, fallopian tube, tubal ligation, postpartum,