Surgical Medical Report

Surgical Medical Report

Patient Information

Patient Name:

[Your Name]

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Female

Contact Information:

123-456-7890

Diagnosis

Preoperative Diagnosis:

  • Acute appendicitis with suspected perforation

Postoperative Diagnosis:

  • Acute appendicitis without perforation

Procedure Performed:

  • Laparoscopic appendectomy

Indications for Surgery

  • The patient presented to the emergency department with complaints of severe right lower quadrant pain, nausea, and vomiting. The physical examination revealed tenderness in the right lower quadrant with rebound tenderness. A CT scan of the abdomen and pelvis confirmed the diagnosis of acute appendicitis, showing an enlarged, non-perforated appendix with surrounding inflammatory changes.

Anesthesia

  • General anesthesia was administered without complications. Preoperative sedation included midazolam (2 mg IV) for anxiolysis.

Surgical Findings

  • Upon laparoscopic exploration, the appendix was found to be enlarged (approximately 10 cm in length) and hyperemic with localized peritoneal inflammation. No evidence of perforation or abscess formation was noted. The surrounding bowel and structures appeared normal.

Operative Technique

  1. Positioning: The patient was placed in a supine position on the operating table, with arms secured at the sides and appropriate padding.

  2. Incision: Three small incisions were made:

    • 10 mm umbilical incision for the laparoscope.

    • Two 5 mm incisions in the right lower quadrant for working instruments.

  3. Procedure Steps:

    • The abdomen was insufflated with carbon dioxide to create a pneumoperitoneum.

    • A laparoscope was inserted through the umbilical incision, and a thorough exploration of the abdominal cavity was performed to assess any additional pathology.

    • The inflamed appendix was identified and carefully dissected free from the surrounding mesenteric tissue using electrocautery.

    • The mesoappendix was clamped, cut, and ligated with absorbable sutures.

    • The base of the appendix was secured with a circular endoscopic stapler, ensuring hemostasis.

    • The appendix was removed through the lateral incision, and the operative field was irrigated with sterile saline to remove any debris.

  4. Closure: The fascial layers of the 10 mm incision were closed with absorbable sutures, while the skin incisions were closed using absorbable sutures and Steri-Strips. A sterile dressing was applied.

Estimated Blood Loss

  • A volume of approximately 50 milliliters is considered minimal for the procedure.

Specimens Obtained

  • The resected appendix was sent for pathological examination to confirm the diagnosis and assess for any atypical findings.

Complications

  • The procedure was completed without any intraoperative complications. The patient was stable throughout the surgery and responded well to anesthesia. There were no issues with bleeding or infection noted.

Postoperative Plan

  • The patient will be monitored in the recovery room for vital signs (BP, HR, O2 saturation) and pain management using IV analgesics (e.g., morphine 2 mg IV as needed).

  • Clear liquids will be initiated postoperatively, progressing to a soft diet as tolerated based on the patient's recovery.

  • Antibiotics (e.g., cefazolin 1 g IV) will be continued for 24 hours postoperatively.

  • The patient will be educated about postoperative care, including incision care, signs of infection, and activity restrictions.

  • A follow-up appointment is scheduled for October 7, 2055, to review pathology results and assess recovery. The patient will be advised to seek immediate medical attention if experiencing fever, increased pain, or other concerning symptoms.

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