Medical Specialty:
Obstetrics / Gynecology

Sample Name: Laparoscopy - 1


Description: Laparoscopy. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case.
(Medical Transcription Sample Report)


The patient was prepped and draped in the usual sterile manner for an abdominoperineal procedure. We began with preparation of the patient by placing a weighted speculum in the posterior vaginal vault. The cervix was grasped with a single-tooth tenaculum. The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. A Foley catheter was inserted into the bladder to drain the bladder. Attention was then turned to the abdomen where an incision was made. This incision was in the umbilicus and was of small caliber--3 mm--in order to allow insertion of the micro-laparoscopic trocar. Three liters of carbon dioxide gas was used to insufflate the abdominal cavity and the micro-laparoscopic trocar was inserted. Then, as noted above, the trocars were inserted into the lower abdominal area as noted in the findings above. Using pelviscopic instruments, all of the above procedures were carried out in the usual manner. The patient tolerated the procedure very nicely. Video documentation was performed throughout. With termination of the procedure, all instruments were removed and the trocar sites were inspected. All 12-mm trocar sites were closed in the fascial layer with #0 Vicryl suture. The 5-mm and 10-mm trocar site incisions were closed with #4-0 Vicryl suture and Steri-Strips. The patient tolerated the operation nicely. The instruments were removed from the pelvic cavity. She was then awakened and taken to the Recovery Room in good condition.

Keywords: obstetrics / gynecology, uterus, cervix, vaginal, single tooth tenaculum, trocar sites, laparoscopy, bladder, laparoscopic, abdominal, cavity, trocar, tooth,