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Sample Type / Medical Specialty: Surgery

The branch of medical science that treats disease or injury by operative procedures.



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Laparoscopic Cholecystectomy - 6
Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.

Laparoscopic Cholecystectomy - 7
Cholecystitis and cholelithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.

Laparoscopic Cholecystectomy - 8
Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.

Laparoscopic Cholecystectomy - 9
Laparoscopic cholecystectomy. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.

Laparoscopic Cholecystectomy & Appendectomy
Symptomatic cholelithiasis. Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970). The patient requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her.

Laparoscopic Cholecystectomy & Cholangiogram
Laparoscopic cholecystectomy with cholangiogram. Acute gangrenous cholecystitis with cholelithiasis. The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.

Laparoscopic Cholecystectomy & Cholangiogram - 1
Laparoscopic cholecystectomy with attempted intraoperative cholangiogram. A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp.

Laparoscopic Cholecystectomy & Liver Cyst Excision
Chronic cholecystitis, cholelithiasis, and liver cyst. Laparoscopic cholecystectomy and excision of liver cyst. Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.

Laparoscopic Cryoablation
Right hand-assisted laparoscopic cryoablation of renal lesions x2. Lysis of adhesions and renal biopsy.

Laparoscopic Gastric Bypass
Morbid obesity. Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis. This is a 30-year-old female, who has been overweight for many years. She has tried many different diets, but is unsuccessful.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are 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 been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples