3 Case 1 OR - Operative Report PDF

Preview

Summary

©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password- protected website for classroom use.OPERATIVE REPORT________________________...

Description

OPERATIVE REPORT______________________________________ Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Admission: 03/27/---Date of Surgery: 03/27/---Surgeon: Rosemary Bumbak, MD Assistant: Michael Gerard, DO Anesthesia: General endotracheal by Dr. Avalon. Estimated Blood Loss: Approximately 1000 mL, requiring transfusion of 2 units of whole blood. Specimen Removed: Portion of the left fallopian tube containing the ectopic pregnancy. Preoperative Diagnosis: Left tubal ectopic pregnancy. Postoperative Diagnoses 1. Ruptured left tubal ectopic pregnancy. 2. Hemoperitoneum. 3. Pelvic adhesions. Surgical Procedures 1. Exploratory laparotomy. 2. Partial salpingectomy. 3. Evacuation of hemoperitoneum. 4. Lysis of adhesions. PROCEDURE IN DETAIL: The patient was prepped and draped in the usual manner and placed under adequate general anesthesia. A Pfannenstiel incision was performed and carried through skin and subcutaneous tissue, fascia, and the peritoneum. The peritoneal cavity was entered. The (Continued) ©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a passwordprotected website for classroom use.

OPERATIVE REPORT Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Surgery: 03/27/---Page 2

hemoperitoneum was noted, and approximately 500 mL of blood was rapidly evacuated from the pelvic cavity, as were large clots. Following this, the bowel was packed away from the pelvic area with packing laps. A retaining retractor was introduced. The left fallopian tube was noted. A large tubal ectopic pregnancy was noted, affecting approximately the distal half of the fallopian tube. Following this, a Heaney clamp was placed in the mesosalpinx and another curved Heaney clamp was placed in the proximal aspect of the left fallopian tube beyond the area of the ectopic pregnancy. A partial salpingectomy was then performed, removing the portion of the left fallopian tube containing the ectopic pregnancy. Heaney clamps were then replaced with sutures of No. 1 Vicryl. Hemostasis was checked again, and no bleeding was detected. Further evacuation of blood and blood clots was then performed. The right fallopian tube was noted to be covered with adhesions, both tubo-ovarian and tubo-uterine adhesions. The adhesions were then sharply lysed, freeing the right fallopian tube. Hemostasis was checked again. No bleeding was detected. Mild serosal abrasion was noted from the area where the ectopic pregnancy was apparently attached to the bowel. This was not bleeding and was very superficial. Hemostasis was checked, and no bleeding was detected. The peritoneum was then closed continuously with 0 chromic suture. The fascia was approximated with interrupted figure-of-8 stitches of 0 Vicryl, and the skin was approximated with the staple gun. (Continued)

©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a passwordprotected website for classroom use.

OPERATIVE REPORT Patient Name: Brenda C. Seggerman Patient ID: 903321 Date of Surgery: 03/27/---Page 3

The patient tolerated the procedure well and left the operating room in satisfactory condition. All counts were correct. Blood loss was estimated at 1000 mL, which was replaced with 2 units of whole blood while in recovery.

________________________ Rosemary Bumbak, MD Obstetrics & Gynecology RB:xx D:03/27/---T:03/27/----

©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a passwordprotected website for classroom use....