Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section & BTL - 1

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,5.  Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:,  200 cc of crystalloids.,URINE OUTPUT:,  300 cc of clear urine at the end of the procedure.,FINDINGS:,  Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  There were bowel adhesions noted through the anterior abdominal wall.  The uterus was noted to be within normal limits.  The tubes and ovaries bilaterally were noted to be within normal limits.  The baby was delivered from the right sacral anterior position without any difficulty.  Apgars 8 and 9.  Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  She had her first C-section because of congenial hip problems.  In her second C-section, baby was breached, therefore, she is scheduled for a third C-section.  The patient also requests sterilization.  Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty.  She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  The fascia was excised in the midline extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors.  There was noted dense adhesions at this point as well as a wire mesh was noted.  The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  The rectus muscle superiorly was opened with a hemostat.  The peritoneum was identified and entered bluntly digitally.  The peritoneal incision was then extended superiorly up to the level of the mesh.  Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally.  The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors.  The amniotic fluid was noted to be clear.  At this point, upon examining the intrauterine contents, the baby was noted to be breached.  The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  The cord was clamped and the baby was then handed off to awaiting pediatricians.  The placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  The uterus was exteriorized and cleared of all clots and debris.  Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp.  The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors.  The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down.  Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  The uterus was then replaced back into the abdomen.  The gutters were cleared of all clots and debris.  The uterine incision was then once again inspected and noted to be hemostatic.  The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  The peritoneum was then closed with #3-0 Vicryl in a running fashion.  Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion.  The fascia was then closed with #0 Vicryl in a running fashion.  The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl.  Then, the skin edges were reapproximated using sterile clips.  The dressing was placed.  The uterus was then cleared of all clots and debris manually.  Then, the patient tolerated the procedure well.  Sponge, lap, and needle, counts were correct x2.  The patient was taken to recovery in sable condition.  She will be followed up throughout her hospital stay.
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DESCRIPTION: Repeat low transverse cesarean section and bilateral tubal ligation (BTL).   Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.

The situation involves a surgical procedure, specifically a repeat low transverse cesarean section and bilateral tubal ligation. This is a significant surgical intervention with potential risks and complications, considering the patient's history of previous cesarean sections and the current breach presentation of the neonate. The stakes are also elevated due to the gestational age of 30 weeks and 4 days, which is preterm, introducing additional concerns for neonatal outcomes. Given these factors, this medical situation is high-stakes, involving both maternal and neonatal health concerns.


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Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 5

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,3.  Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 300 cc.,URINE OUTPUT:,  80 cc of clear urine.,FLUIDS: , 2000 cc of crystalloids.,COMPLICATIONS: , None.,FINDINGS: , A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.,INDICATIONS: , This patient is a 21-year-old gravida 3, para 1-0-1-1 Caucasian female who presented to Labor and Delivery in labor.  Her cervix did make some cervical chains.  She did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head.  However, on exam unable to delineate the facial structures, but definite fetal malpresentation.  The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring.  The contraction pattern was inadequate.  It was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended.  All the questions were answered.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt.  Prior to this, the spinal anesthesia was administered.  The patient was then prepped and draped.  A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline and extended laterally using Mayo scissors.  The superior aspect of the rectus fascia was then grasped with Ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was then identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneum was then gently stretched.  The vesicouterine peritoneum was then identified, tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors.  The uterus was entered with the second scalpel and large transverse incision.  This was then extended in upward and lateral fashion bluntly.  The infant was then delivered atraumatically.  The nose and mouth were suctioned.  The cord was then clamped and cut.  The infant was handed off to the awaiting pediatrician.  The placenta was then manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was then repaired using #0 chromic in a running fashion marking a U stitch.  A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis.  The uterus was then returned to the anatomical position.  The abdomen and the gutters were cleared of all clots.  Again, the incision was found to be hemostatic.  The rectus muscle was then reapproximated with #2-0 Vicryl in a single interrupted stitch.  The rectus fascia was then repaired with #0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion.  This was palpated and the patient was found to be without defect and intact.  The skin was then closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will be followed up as an inpatient with Dr. X.
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DESCRIPTION: Primary low transverse cervical cesarean section.  Intrauterine pregnancy at 38 weeks and malpresentation.  A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.

surgery, low transverse cervical cesarean section, cesarean section, pregnancy, neonate, metzenbaum scissors, intrauterine pregnancy, rectus fascia, rectus muscle, intrauterine, peritoneum, malpresentation, transverse, astramorph,

The situation involves an obstetric surgical procedure, specifically a cesarean section, due to fetal malpresentation at 38 weeks of pregnancy. While C-sections are commonly performed procedures, they are inherently high-stakes due to the risks involved for both the mother and the neonate. Factors such as anesthesia, potential for complications, and the need for informed consent contribute to the high-stakes nature. The success of this procedure, evidenced by the absence of complications and the healthy status of the newborn, indicates proper management of these stakes.

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Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section & BTL

PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,POSTOPERATIVE DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:,  A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9.  There was normal pelvic anatomy, normal tubes.  The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip.  The abdomen was prepped and draped in a sterile fashion.  A Pfannenstiel incision was made and carried sharply down to the level of fascia.  The fascia was incised transversely.  The fascia was dissected away from the underlying rectus muscles.  With sharp and blunt dissection, rectus muscles were divided in midline.  The perineum was entered bluntly.  The incision was carried vertically with scissors.  Transverse incision was made across the bladder peritoneum.  The bladder was dissected away from the underlying lower uterine segment.  Bladder retractor was placed to protect the bladder.  The lower uterine segment was entered sharply with a scalpel.  Incision was carried transversely with bandage scissors.  Clear amniotic fluids were encountered.  The infant was out of the pelvis and was in oblique vertex presentation.  The head was brought down into the incision and delivered easily as were the shoulders and body.  The mouth and oropharynx were suctioned vigorously.  The cord was clamped and cut.  The infant was passed off to the waiting pediatrician in satisfactory condition.  Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact.  Uterus was explored and found to be empty.  Uterus was delivered through the abdominal incision and massaged vigorously.  Intravenous Pitocin was administered.  T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis.  Secondary running locking stitch was placed for extra strength to the wound.  At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut.  Intervening knuckle was excised and passed off the field.  The proximal end of the tubal mucosa was cauterized.  Cul-de-sac and gutters were suctioned vigorously.  The uterus was returned to its proper anatomic position in the abdomen.  The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl.  Uterus was expressed of its contents.  Patient was brought to the recovery room in satisfactory condition.  There were no complications.  There was 600 cc of blood loss.  All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.
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DESCRIPTION: Repeat low transverse cesarean section and bilateral tubal ligation (BTL).  Intrauterine pregnancy at term with previous cesarean section.  Desires permanent sterilization.  Macrosomia.

surgery, placenta, low transverse cesarean section, bilateral tubal ligation, permanent sterilization, cesarean section, intrauterine, btl, sterilization, macrosomia, uterine,

The situation describes a surgical procedure involving a repeat low transverse cesarean section and bilateral tubal ligation. While this is a common and generally safe procedure, it is still a surgery, which comes with inherent risks such as anesthesia complications, infection, and significant blood loss (600 cc in this case). Additionally, the procedure is irreversible in terms of sterilization, adding weight to the decision. Considering these factors, the stakes are moderately high as the outcome directly impacts the patient's health and future fertility intentions.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Arrest of dilation.,PROCEDURE PERFORMED:,  Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces.  Apgars were 9 at 1 minute and 9 at 5 minutes.  Normal uterus, tubes, and ovaries were noted.,INDICATIONS:  ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation.  The patient progressed to 8 cm, at which time, Pitocin was started.  She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm.  A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where epidural anesthesia was found to be adequate.  The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt.  A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors.  The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was inserted.  The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors.  This incision was extended laterally and the bladder flap was created digitally.  The bladder blade was reinserted.  The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction.  Clear fluid was noted.  The infant was subsequently delivered atraumatically.  The nose and mouth were bulb suctioned.  The cord was clamped and cut.  The infant was subsequently handed to the awaiting nursery nurse.  Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform.  Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic suture.  Hemostasis was visualized.  The uterus was returned to the abdomen.,The pelvis was copiously irrigated.  The uterine incision was reexamined and was noted to be hemostatic.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
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DESCRIPTION: Primary low-transverse cesarean section.

surgery, intrauterine pregnancy at term, arrest of dilation, cephalic presentation, low transverse cesarean section, cesarean section, rectus muscles, intrauterine,

A primary low-transverse cesarean section is a common surgical procedure typically used to deliver a baby when vaginal delivery isn't possible or safe, as in this case due to the arrest of dilation. Despite some potential risks like bleeding (estimated at 1000 mL) and complications inherent to any surgery, the procedure was performed without complications, and both the mother and baby were stable post-operation. Given that this is a routine and well-practiced procedure in obstetric surgery, and no complications occurred, the situation isn't extremely high-stakes. However, the context of any surgery involving childbirth does carry inherent importance and urgency. Therefore, this follows a moderately high-stakes situation due to the critical nature of delivering a baby safely.


Medical Specialty: Surgery
Sample Name: Lobectomy & Lymphadenectomy

PREOPERATIVE DIAGNOSIS:  ,Right lower lobe mass, possible cancer.,POSTOPERATIVE DIAGNOSIS: , Non-small cell carcinoma of the right lower lobe.,PROCEDURES:,1.  Right thoracotomy.,2.  Extensive lysis of adhesions.,3.  Right lower lobectomy.,4.  Mediastinal lymphadenectomy.,ANESTHESIA: , General.,DESCRIPTION OF THE PROCEDURE: , The patient was taken to the operating room and placed on the operating table in the supine position.  After an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion.  Lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue.  The latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly.  The chest was entered through the fifth intercostal space.  A retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection.  The right lower lobe was identified.  There was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not.  Dissection was then performed at the lower lobe of the fissure, and a GIA stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe.  Then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected.  The inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a TA30 stapler and then transected.  Further dissection of the fissure allowed for its completion with a GIA stapler and then the bronchus was identified and dissected.  The bronchus was stapled with a TA30 bronchial stapler and then transected, and the specimen was removed and sent to the Pathology Department for frozen section diagnosis.  The frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free.  The mediastinum was then explored.  No nodes were identified around the pulmonary ligament or around the esophagus.  Subcarinal nodes were dissected, and hemostasis was obtained with clips.  The space below and above the osseous was opened, and the station R4 nodes were dissected.  Hemostasis was obtained with clips and with electrocautery.  All nodal tissue were sent to Pathology as permanent specimen.  Following this, the chest was thoroughly irrigated and aspirated.  Careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 Prolene sutures.  Then, two #28 French chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches.  The incision was then closed with interrupted #2-0 Vicryl pericostal stitches.  A running #1 PDS on the muscle layer, a running 2-0 PDS in the subcutaneous tissue, and staples on the skin.  A sterile dressing was applied, and the patient was then awakened and transferred to the following Intensive Care Unit in stable and satisfactory condition.,ESTIMATED BLOOD LOSS: , 100 mL.,TRANSFUSIONS:,  None.,COMPLICATIONS:,  None.,CONDITION: , Condition of the patient on arrival to the intensive care unit was satisfactory.
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DESCRIPTION: Right lower lobectomy, right thoracotomy, extensive lysis of adhesions, mediastinal lymphadenectomy.

surgery, right lower lobe, gia stapler, mediastinal, non-small cell carcinoma, cancer, frozen section, hilum, lobectomy, lymphadenectomy, lysis of adhesions, pleura, thoracotomy, upper lobe, lower lobectomy, adhesions, chest

The case involves a surgical procedure for a patient diagnosed with non-small cell carcinoma, a type of lung cancer. The surgical interventions, including right thoracotomy and lobectomy, are high-stakes due to the complexity and potential risks associated with thoracic surgeries. The stakes are further elevated by the need for precise removal of cancerous tissue while maintaining the patient's lung function and minimizing complications. Moreover, cancer surgeries have significant implications for the patient's long-term prognosis and quality of life. Therefore, considering the medical complexity and the impact on the patient's health, this scenario is high-stakes.


Medical Specialty: Surgery
Sample Name: Low -Segment C-Section

PREOPERATIVE DIAGNOSIS:  ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section.  The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner.  A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia.  Bleeding points were snapped and coagulated along the way.  The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles.  These were divided in the midline revealing the peritoneum, which was opened vertically.  The uterus was in mid position.  The bladder flap was incised elliptically and reflected caudad.  A low transverse hysterotomy incision was then constructed and extended bluntly.  Amniotomy revealed clear amniotic fluid.  A live born vigorous male infant was then delivered from the right occiput transverse position.  The infant breathed and cried spontaneously.  The nares and pharynx were suctioned.  The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team.  Cord blood samples were obtained.  The placenta was manually removed and the uterus was eventrated for closure.  The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first.  Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl.  The cornual sac and gutters were irrigated.  The uterus was returned to the abdominal cavity.  The adnexa were inspected and were normal.  The abdomen was then closed in layers.  Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips.  Blood loss was estimated at 700 mL.  All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.
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DESCRIPTION: Primary low segment cesarean section.

Primary low segment cesarean section.

surgery, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,

This is a surgical procedure involving a cesarean section due to pregnancy at 42 weeks with non-reassuring fetal testing and failed induction. While cesarean sections are common and often routine, they do carry inherent surgical risks for both the mother and the infant, including the risk of infection, blood loss, and complications from anesthesia. The stakes are heightened by the context of non-reassuring fetal status and failed induction. However, the document indicates that the procedure went smoothly, and both mother and baby were stable postpartum, which mitigates some of the immediate high-stakes implications.


Medical Specialty: Surgery
Sample Name: Lobectomy & Lymph Node Dissection

OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.
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DESCRIPTION: Right upper lung lobectomy.  Mediastinal lymph node dissection

surgery, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches

The operation described involves a lobectomy and lymph node dissection, which are surgical procedures typically performed to treat lung cancer or other serious conditions. This is high-stakes because it involves removing a portion of the lung and is significant surgery requiring general anesthesia, which carries inherent risks such as complications from anesthesia, bleeding, and infection. Additionally, the outcome of the surgery can significantly impact the patient's prognosis and quality of life, particularly if cancer is involved.


Medical Specialty: Surgery
Sample Name: Lobectomy - Left Lower

OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.
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DESCRIPTION: Left lower lobectomy.

Left lower lobectomy.

surgery, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy,

A left lower lobectomy is a significant surgical procedure involving the removal of a lobe of the lung, typically due to conditions such as lung cancer. It involves precise surgical techniques and has critical implications for a patient's health and recovery. The stakes are moderately high because of the potential for complications, the need for careful post-operative monitoring, and the impact on the patient’s quality of life. The procedure's success directly affects the patient's health outcomes and their risk of recurrence if cancerous cells are present. Therefore, proper execution and follow-up care are crucial.


Medical Specialty: Surgery
Sample Name: Lipoma Excision - 1

PREOPERATIVE DIAGNOSIS:,  Mass, left knee.,POSTOPERATIVE DIAGNOSIS: , Lipoma, left knee.,PROCEDURE PERFORMED: ,Excision of lipoma, left knee.,ANESTHESIA: , Local with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.,HISTORY:,  The patient is a 35-year-old female with history of lump on her right knee for the past, what she reports to be six years.  She states it had grow in size over the last six months, rarely causes her any discomfort or pain, denies any neurovascular complaints of her right lower extremity.  She denies any other lumps or bumps on her body.  She wishes to have this removed for cosmetic reasons.,PROCEDURE: , After all potential risks, benefits, and complications of the procedure were discussed with the patient, informed consent was obtained.  She was transferred from the Preoperative Care Unit to Operating Suite #1.  She was transferred from the gurney to the operating table.  All bony prominences were well padded.  A well padded tourniquet was applied to her right thigh.  Anesthesia then administered some sedation, which she tolerated well.  Her right lower extremity was then sterilely prepped and draped in normal fashion.  Next, a rubber Esmarch was used to exsanguinate her right lower extremity.,Next, approximately 20 cc of 0.25% Marcaine with 1% lidocaine were used to locally anesthetize her anterior medial right knee in location of the mass.  Next, a #15 blade Bard-Parker scalpel was utilized to make an approximately 3 cm vertical incision over the soft tissue mass upon incising the skin and the subcutaneous tissue readily and there was the aforementioned fatty tissue mass.  This was easily excised with blunt dissection.  Examination of the wound then revealed a second piece of fatty tissue, which resembled a lipoma measuring approximately 1.5 cm x 2 cm.  This was then also excised utilizing Littler scissors.  Hemostasis was obtained.  The wound was then copiously irrigated after this all the underlying bone tissue was removed.  #2-0 Vicryl interrupted subcutaneous sutures were then placed and the skin was reapproximated utilizing #4-0 horizontal mattress nylon sutures.  Sterile dressings was applied of Adaptic, 4x4s, and Kerlix as well as an Ace wrap.  Sedation was reversed.  Tourniquet was deflated.  The patient was transferred from the operating table to the gurney and to the Postoperative Care Unit in stable condition.  Her prognosis for this is good.
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DESCRIPTION: Excision of lipoma, left knee.  A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.

surgery, excision of lipoma, adipose tissue, fatty tissue, lipoma, tissue, knee

The lipoma excision is a routine surgical procedure typically performed for cosmetic reasons or to relieve minor discomfort. The surgery involves minimal risk and was performed under local anesthesia with sedation. There were no complications during the procedure, and the patient is expected to have a good prognosis. While any surgical procedure carries some inherent risks, this situation is not characterized by life-threatening conditions or serious complications.


Medical Specialty: Surgery
Sample Name: Lipectomy - Breast

PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position.  Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy.  An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold.  A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle.  200 cc was infiltrated on each side.  This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula.  This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position.  This would result in an elevation of the nipple-areolar complex with transposition.  The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle.  Hemostasis was achieved with electrocautery.  After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple.  Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture.  Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing.  The patient tolerated the procedure well.  The patient was returned to recovery room in satisfactory condition.
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DESCRIPTION: Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.

surgery, breast ptosis, dermabond, mammary hypertrophy, monocryl, anesthesia, breast tissue, endotracheal anesthesia, lipectomy, mastopexies, mastopexy, nipple, nipple-areolar complex, suction assisted lipectomy, nipple areolar complex, lactated ringers, nipple areolar, areolar complex, epithelialization, areolar, breast,

The described procedure is a suction-assisted lipectomy of the breast, which is a surgical procedure to address mammary hypertrophy and breast ptosis. It involves general endotracheal anesthesia, removal of breast tissue, and mastopexies, which are operations to lift and reshape the breasts. While surgery always carries inherent risks such as those related to anesthesia and infection, lipectomy and mastopexies are generally considered routine procedures within cosmetic or reconstructive plastic surgery. The patient tolerated the procedure well and was in satisfactory condition post-surgery, indicating no immediate complications. Although there are risks due to the nature of surgical intervention, it doesn't fall into an emergency life-threatening category, hence it is of moderate stakes.


Medical Specialty: Surgery
Sample Name: Lipoma Excision

PREOPERATIVE DIAGNOSIS:,  Mass lesion, right upper extremity.,POSTOPERATIVE DIAGNOSIS: , Intramuscular lipoma, right arm, approximately 4 cm.,PROCEDURE PERFORMED:  ,Excision of intramuscular lipoma with flap closure by Dr. Y.,INDICATIONS FOR PROCEDURE:  ,This is a 77-year-old African-American female who presents as an outpatient to the General Surgical Service with a mass in the anterior aspect of the mid-biceps region of the right upper extremity.  The mass has been increasing in size and symptoms according to the patient.  The risks and benefits of the surgical excision were discussed.  The patient gave informed consent for surgical removal.,GROSS FINDINGS: , At the time of surgery, the patient was found to have intramuscular lipoma within the head of the biceps.  It was removed in its entirety and submitted to Pathology for appropriate analysis.,PROCEDURE: , The patient was taken to the operating room.  She was given intravenous sedation and the arm area was sterilely prepped and draped in the usual fashion.  Xylocaine was utilized as local anesthetic and a longitudinal incision was made in the axis of the extremity.  The skin and subcutaneous tissue were incised as well as the muscular fascia.  The fibers of the biceps were divided bluntly and retracted.  The lipoma was grasped with an Allis clamp and blunt and sharp dissection was utilized to remove the mass without inuring the underlying neurovascular structures.  The mass was submitted to Pathology.  Good hemostasis was seen.  The wound was irrigated and closed in layers.  The deep muscular fascia was reapproximated with #2-0 Vicryl suture.,The subcutaneous tissues were reapproximated with #3-0 Vicryl suture and the deep dermis was reapproximated with #3-0 Vicryl suture.  Re-approximated wound flaps without tension and the skin was closed with #4-0 undyed Vicryl in running subcuticular fashion.  The patient was given wound care instructions and will follow up again in my office in one week.  Overall prognosis is good.
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DESCRIPTION: Intramuscular lipoma, right upper extremity.  Excision of intramuscular lipoma with flap closure.

surgery, excision, mass lesion, intramuscular, muscular fascia, vicryl suture, intramuscular lipoma, suture, mass, lipoma

The procedure described is a surgical excision of an intramuscular lipoma, a relatively common and typically low-risk surgical procedure. The patient is an outpatient, and the surgery involves careful dissection to avoid injury to surrounding structures. The report indicates that the surgery was completed successfully with good hemostasis, and the prognosis is good. While any surgery carries some risk, this particular procedure does not appear to involve critical life-threatening risks or significant complications.


Medical Specialty: Surgery
Sample Name: Liver Biopsy

TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL:  ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today.  The patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death.  The risks and benefits of the procedure were understood, and the patient signed the consent form freely.,With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.  The area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver.  Next, a small incision was made with a Bard-Parker #11 scalpel.  A 16-gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration.  Liver cores measuring *** cm were obtained and will be sent to Pathology for routine histologic study.,POST-PROCEDURE COURSE AND DISPOSITION: , The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication.  Normal activities can be resumed tomorrow.  The patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop.  An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,COMPLICATIONS:,  None.,RECOMMENDATIONS: , Prior to discharge, hepatitis A and B vaccines will be recommended.  Risks and benefits for vaccination have been addressed and the patient will consider this option.
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DESCRIPTION: Percutaneous liver biopsy.   With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.

surgery, bile peritonitis, bowel perforation, pneumothorax, klatskin needle, mid axillary, liver biopsy, percutaneous, lidocaine, biopsy, liver

The percutaneous liver biopsy is a medical procedure with significant risks, including bleeding, bile peritonitis, bowel perforation, pneumothorax, or death, as discussed in the procedure details. The mention of potential severe complications and the necessity for patient consent highlight the procedure's high-stakes nature. However, considering that it is a routine procedure performed with standard precautions and no complications occurred, the situation can be deemed moderately high-stakes.


Medical Specialty: Surgery
Sample Name: Ligament Reconstruction & Tendon Interposition Arthroplasty

OPERATION PERFORMED:,  Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint.  Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field.  Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium.  An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint.  Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon.  The radial beak of the trapezoid was then osteotomized off the head of the scaphoid.  The proximal metacarpal was then fenestrated with a 4.5-mm drill bit.  Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision.  The FCR tendon was divided and this incision was closed with 4-0 nylon sutures.  Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal.  A bone anchor was then placed distal to the metacarpal fenestration.  The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position.  The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor.  Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect.  The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire.  The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Ligament reconstruction and tendon interposition arthroplasty of right wrist.

surgery, arthroplasty, ligament, tendon, fcr, tendon interposition arthroplasty, ligament reconstruction, reconstruction, trapezium, metacarpal, joint, interposition,

The surgical procedure described involves ligament reconstruction and tendon interposition arthroplasty of the right wrist, which is a complex and intricate surgery. This type of procedure requires a high level of precision and expertise due to the delicate manipulation of tendons, nerves, and bones in the wrist area. Mistakes or complications can lead to significant impacts on the patient's hand function, which underscores the stakes involved in this operation. Additionally, there are inherent risks associated with any surgery, such as infection, anesthesia complications, and the potential for incomplete recovery if the procedure is not successful. Given the technical complexity and the critical nature of the procedure for the patient's mobility and quality of life, this situation is considered high-stakes.


Medical Specialty: Surgery
Sample Name: Laryngoscopy & Vocal Cord Biopsy

PREOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,PROCEDURE PERFORMED:  ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:  The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office.  Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia.  A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx.  The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords.  The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third.  The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region.  The patient's anterior commissure appeared to be clear.  The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord.  Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect.  The patient's subglottic region was very edematous and with redundant mucosal tissue.  The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch.  The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps.  After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis.  The specimen was passed off the field and was sent to Pathology for evaluation.  Hemostasis was maintained on the left side.  Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand.  The Zeiss operating microscope was then brought into view to directly visualize the vocal cords.  The biopsies were taken under direct visualization utilizing the Zeiss operating microscope.  After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full.  This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen.  The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions.  A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions.  There were no signs of any palpable cervical lymphadenopathy.  The tooth guard was removed and the patient was then turned back to anesthesia.  The patient did receive intraoperatively 10 mg of Decadron.  The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well.  The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.
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DESCRIPTION: Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.  Hoarseness, bilateral true vocal cord lesions, and leukoplakia.

surgery, direct laryngoscopy, zeiss operating microscope, vocal cord lesions, vocal cord, cord, vocal, microscopic, laryngoscopy, hoarseness, biopsy, leukoplakia

The described situation involves a surgical procedure to address vocal cord lesions and leukoplakia in a patient with chronic hoarseness. While the procedure is routine and the reported blood loss is minimal with no complications, it involves the biopsy of vocal cords which are critical to voice function. The presence of leukoplakia and the need for biopsy raises concerns of possible malignancy, making it a situation with potentially serious implications for the patient's health and quality of life. However, the procedure itself, as described, is not emergent or life-threatening. Therefore, I would consider this situation moderately high-stakes due to the implications of the biopsy results and the critical area being treated.


Medical Specialty: Surgery
Sample Name: Leaking ET tube

ASSESSMENT:  ,The patient needed reintubation due to a leaking tube.  I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure.,Using Versed and succinylcholine, we were able to sedate and paralyze him to perform the procedure.  His potassium this morning was normal.  Using an 8.5 ET tube under direct visualization, the tube was passed through the cords.  The patient tolerated the procedure extremely well.  Auscultation of the lungs revealed bilateral equal breath sounds.  Chest x-ray is pending.  CO2 monitor was positive.
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DESCRIPTION: The patient needing to be reintubated due to a leaking ET tube.  The patient is recently postoperative.

surgery, et tube, reintubated, postoperative, leakingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation involves a surgical patient who required reintubation due to a leaking endotracheal (ET) tube. Reintubation itself can be a high-stakes procedure, as it involves securing the airway in a potentially unstable patient. The fact that the patient is postoperative adds additional risk considerations, including complications related to anesthesia or airway management. The appropriate use of sedation and successful intubation indicates that the immediate situation was managed well, but there are potential underlying risks if the intubation fails or if the patient has complications post-procedure. The pending chest x-ray is also a critical component to ensure proper placement and to rule out further complications like pneumothorax.


Medical Specialty: Surgery
Sample Name: Laryngoscopy

PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.
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DESCRIPTION: Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.

surgery, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent,

The situation described involves a surgical procedure to address subglottic upper tracheal stenosis in a 76-year-old patient. This condition can severely impact breathing, thus affecting the patient's quality of life. The stakes are high due to the patient's age, the complexity of the procedure, and the potential complications that were discussed prior to surgery, such as bleeding, infection, or airway obstruction. Even though the immediate surgery was successful, the risks inherent in any invasive procedure and the possibility of recurrent stenosis or need for future interventions contribute to the situation being high-stakes. The patient's prior medical history and the indication that previous surgeries were insufficient also elevate the stakes.


Medical Specialty: Surgery
Sample Name: Laryngectomy & Thyroid Lobectomy

TITLE OF OPERATION:,  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07.  Subsequently, biopsy confirmed tumor persistence in the right glottic region.  Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail.  Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level.  The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives.  He was accompanied by his wife and daughter.  Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table.  After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm.  A #6 endotracheal tube was placed initially.  Direct laryngoscopy was performed with a Lindholm laryngoscope.  A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis.  Subsequently, a decision was then made to go ahead and perform the surgical intervention.  A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected.  A shoulder roll was applied after the patient was prepped and draped in a sterile fashion.  Subsequently, a hemi-apron incision was performed.  Subplatysmal flaps were raised at the hyoid bone into the clavicle.  Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed.  Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle.  Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle.  The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified.  Level 2A contents were then dissected off the floor of the neck including levels 3 and 4.  Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4.  The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve.  Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed.  Subsequently, the strap muscles were separated in the midline.  The trachea was identified in the midline.  The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage.  Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively.  The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular.  Attention was then turned to performing a cricothyrotomy.  Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision.  A #7 anode tube was then placed in this area and secured.  Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis.  Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine.  It was evident that this tumor had extended more than 1 cm into the subglottic region.  Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded.  Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy.  Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin.  A W-plasty was also performed to allow for enlargement of the stoma.  Attention was then turned to identifying the common parting wall of the trachea and the esophagus.  Attention was then turned to resecting the hyoid bone.  The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism.  The wound was copiously irrigated.  Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect.  Once this was performed, a running 3-0 canal stitch was used to close the pharynx.  Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied.  Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon.  The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin.  The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.
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DESCRIPTION: Squamous cell carcinoma of the larynx.  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.

surgery, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage

The described procedure involves a complex and highly invasive surgery for a 58-year-old patient with persistent and potentially invasive laryngeal cancer. The stakes are high due to the nature of the cancer, the risks associated with the surgery (including anesthesia, possible nerve damage, and loss of speech and swallow functions), and the complexity of the surgical interventions, including total laryngectomy and neck dissection. These factors make the situation high-stakes, impacting the patient's quality of life significantly, and requiring careful postoperative management. Successful execution and potential complications could have life-altering consequences for the patient.


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Medical Specialty: Surgery
Sample Name: Laparotomy & Salpingectomy

PREOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,POSTOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,PROCEDURE PERFORMED:,  Exploratory laparotomy and right salpingectomy.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity.  Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS:  ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain.  The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate.  Evaluation in the emergency room reveals a second right ectopic pregnancy.  Her beta quant was found to be approximately 13,000.  The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity.  Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy.  The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery.  Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where general anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors.  The rectus muscles were dissected in the midline.  The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder.  At this time, the blood found in the abdomen was suctioned.  The bowel was packed with moist laparotomy sponge.  The right ectopic pregnancy was identified.  The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture.  Hemostasis was visualized.  At this time, the left tube and ovary were examined and were found to be normal in appearance.  The pelvis was cleared off clots and was copiously irrigated.  The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed.  The rectus muscles were reapproximated using 3-0 Vicryl.  The fascia was reapproximated with #0 Vicryl sutures.  The subcutaneous layer was closed with 3-0 plain gut.  The skin was closed with 4-0 Monocryl.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
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DESCRIPTION: Exploratory laparotomy and right salpingectomy.

surgery, ectopic pregnancy, salpingectomy, exploratory laparotomy, fallopian tube, mayo scissors, rectus muscles,

The situation involves a surgical procedure for an ectopic pregnancy, which is inherently high-stakes due to the medical risks associated, such as internal bleeding and potential for life-threatening complications. The patient's condition prior to surgery, including severe abdominal pain and tachycardia, further intensify the high-stakes nature of the situation. Ectopic pregnancy surgeries require swift and precise action to prevent severe complications or death, which underscores the importance and urgency typical of high-stakes situations in medical practice.


Medical Specialty: Surgery
Sample Name: Laparoscopy & Sigmoidoscopy

PREOPERATIVE DIAGNOSES:,1.  Acute pain.,2.  Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1.  Acute pain.,2.  Fever postoperatively.,3.  Hemostatic uterine perforation.,4.  No bowel or vascular trauma.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:,  None.,INDICATIONS:  ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03.  The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2.  The patient denied any nausea, vomiting or diarrhea.  She does complain of some frequent urination.  Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated.  On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus.  There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac.  The bilateral tubes and ovaries appeared normal.  There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap.  There is no evidence of injury to the bowel or pelvic sidewall.  The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered.  The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  Veress needle was placed through this incision and the gas turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  A 11 mm trocar was then placed through this incision.  The camera was placed with the above findings noted.  A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline.  A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs.  The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline.  At this point, Dr. X was consulted.  He performed a rigid sigmoidoscopy, please see his dictation for further details.  There does not appear to be any evidence of colonic injury.  The saline in the pelvis was then suctioned out using Nezhat-Dorsey.  All instruments were removed.  The 5 mm trocar was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar removed.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief.  Steri-Strips were then placed across the incision.  The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of the procedure.  The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.
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DESCRIPTION: Diagnostic laparoscopy and rigid sigmoidoscopy.  Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.

surgery, uterine perforation, vascular, bowel, diagnostic laparoscopy, vulsellum tenaculum, uterine manipulator, excellent hemostasis, rigid sigmoidoscopy, laparoscopy, sigmoidoscopy, postoperatively, trocar,

The situation involves a surgical procedure, particularly a diagnostic laparoscopy and rigid sigmoidoscopy following a post-operative complication of acute pain and fever after a previous hysteroscopy and dilation curettage. Such medical situations typically involve significant health considerations and require careful post-operative monitoring, thus elevating the stakes. Although the procedure was reported to be without complications and the patient was in satisfactory condition post-procedure, the context still involves addressing a uterine perforation, which demands timely and effective medical intervention to prevent further complications. However, since the operation ended with no complications and the perforation was hemostatic (not actively bleeding), it moderately reduces the immediacy of high risk, yet remains a critical surgical situation.


Medical Specialty: Surgery
Sample Name: Laparotomy & Myomectomy

PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,PROCEDURE PERFORMED:,1.  Laparotomy.,2.  Myomectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS:  ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium.  Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position.  After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife.  This was carried through the underlying layer of fascia with a second knife.  The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly.  It was then dissected in the middle with the Mayo scissors.  The inferior aspect of this incision was addressed in a similar manner.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly.  Next, the uterus was grasped bluntly and removed from the abdomen.  The fundal fibroid was identified.  It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels.  15 cc was injected.  Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen.  The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger.  The fibroid was easily and bluntly dissected out.  It was also grasped with Lahey clamp to prevent traction.  Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse.  The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed.  At this point, several smaller fibroids were noticed along the endometrial surface of the uterus.  Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size.  These were also handed to the scrub tech.  Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch.  The uterus was seen to be completely hemostatic after closure.  Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline.  The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed.  Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline.  Then the fascia was closed with #0 Vicryl in a running fashion.  Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately.  After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.
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DESCRIPTION: Laparotomy and myomectomy.   Enlarged fibroid uterus and blood loss anemia.  On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.

surgery, enlarged fibroid uterus, blood loss anemia, laparotomy, myomectomy, metzenbaum scissors, uterus, fibroid, rectus, fascia, scissors, fashion, clamps, enlarged, incision, bluntly,

The situation described involves a surgical procedure, namely a laparotomy and myomectomy, which are invasive surgeries conducted to remove fibroids from the uterus. While the procedure was completed without complications and the estimated blood loss was minimal, surgery always carries inherent risks such as infection, bleeding, or adverse reactions to anesthesia. This is compounded by the presence of conditions like blood loss anemia, which requires careful management during surgery. The stakes are raised in a surgical context due to these potential complications and the need for precise execution and monitoring of the patient's condition post-procedure.


Medical Specialty: Surgery
Sample Name: Laparoscopy - Drainage of Cyst

PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.
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DESCRIPTION: Diagnostic laparoscopy and drainage of cyst.

surgery, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian,

The procedure described is a standard surgical operation for draining an ovarian cyst using minimally invasive techniques (laparoscopy). While surgery always carries some inherent risk, this type of procedure is quite routine and generally has a high success rate with low complication risks. The systematic and successful completion of the procedure further indicates low immediate stakes as the patient was stable and taken to recovery in good condition. Moreover, the operation did not reveal any unexpected findings or complications, which often would elevate the stakes.


Medical Specialty: Surgery
Sample Name: Laparoscopic Hysterectomy

PREOPERATIVE DIAGNOSIS:,  Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:,  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer.  She was counseled to undergo laparoscopic staging.,FINDINGS:,  During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries.  No ascites was present.  On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered.  She was placed in a low anterior lithotomy position using Allen stirrups.  The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine.  There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports.  The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty.  The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed.  There were no adhesions underlying the previous vertical midline scar.  The 10-mm port was placed in the umbilicus, and the laparoscope was inserted.  Remaining ports were placed under direct laparoscopic guidance.  Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy.  An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum.  The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached.  Pedicles were sealed and divided with bipolar cutting forceps.  Excellent hemostasis was noted.  Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery.  Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps.  The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially.  The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally.  The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy.  The right infundibulopelvic ligament was divided using the bipolar cutting forceps.  The mesovarium was skeletonized.  A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder.  Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring.  The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries.  The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum.  The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device.  The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen.  The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture.  The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released.  The umbilical port was removed using laparoscopic guidance.  The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl.  The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened and taken to the post anesthesia care unit in stable condition.
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DESCRIPTION: Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.

surgery, endometrial carcinoma, laparoscopic hysterectomy, total laparoscopic hysterectomy, laparoscopic staging, lymphadenectomy, pelvic, obturator, lymph node dissection, direct laparoscopic guidance, tubes and ovaries, bipolar cutting forceps, node dissection, koh colpotomy, iliac artery, infundibulopelvic ligament, laparoscopic guidance, retroperitoneal duodenum, lymph node, laparoscopic, hysterectomy, endometrial, pneumoperitoneum, washings, vaginal, retroperitoneal, forceps, bipolar,

The described situation involves a surgical procedure for the treatment of endometrial carcinoma. This is a high-stakes situation because it pertains to cancer treatment, which directly affects the patient's health and prognosis. The complexity of the surgery, which involves staging and removing cancerous tissues, also adds to the high stakes. Any complications during the procedure could have significant consequences on the patient's recovery and outcomes.


Medical Specialty: Surgery
Sample Name: Laparoscopic Pyeloplasty

PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.
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DESCRIPTION: Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.

surgery, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,

This surgical procedure involves complications like severe intraabdominal adhesions and retroperitoneal fibrosis, resulting in the transition from a laparoscopic to an open surgery. The patient's pre-existing conditions and the inability to safely proceed with the initial laparoscopic approach heighten the stakes, given the potential risks during open surgery, such as bleeding or organ damage. While the situation is managed by the surgical team, the inherent risks and need for an open surgery elevate the stakes.