Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Fulguration - Laparoscopic

Description: Laparoscopic tubal fulguration.
(Medical Transcription Sample Report)

The patient was taken to the operating room, and under general anesthesia, placed in the dorsal lithotomy position, prepped and draped in the usual sterile fashion. Examination under anesthesia revealed the uterus to be anteverted, firm, mobile and normal size. No adnexal masses palpated. A weighted retractor was placed in the posterior vault of the vagina, and the anterior lip of the cervix was grasped with an Allis clamp and pulled forward. A Cohen cannula was placed in the endocervical canal and attached to the Allis clamp to be used for uterine manipulation during laparoscopy. The weighted speculum was withdrawn.

A 1 cm infraumbilical skin incision was made. Through this a Veress needle was inserted into the abdominal cavity. The abdomen was filled with approximately 2 liters of CO2 gas. The Veress needle was withdrawn. A trocar sleeve was placed through the incision into the abdominal cavity. The trocar was withdrawn and replaced with the laparoscope. A 1 cm suprapubic skin incision was made. Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope. The trocar was withdrawn and replaced with a probe.

The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis. Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal. The probe was withdrawn and replaced with the bipolar cautery instrument. The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus. Electrical current was applied to the tube at this point and fulgurated. The tube was then regrasped just distal to this and refulgurated. It was then regrasped just distal to the lateral point and refulgurated again. The same procedure was then carried out on the opposite tube. The bipolar cautery instrument was withdrawn and replaced with the probe. The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes. The upper abdomen was visualized, and the liver surface was normal. The gas was allowed to escape from the abdomen, and the instruments were removed. The skin incisions were repaired. The instruments were removed from the vagina.

There were no complications to the procedure. Blood loss was minimal. The patient went to the postanesthesia recovery room in stable condition.

Keywords: obstetrics / gynecology, tubal fulguration, cohen cannula, laparoscopic, trendelenburg position, veress needle, abdominal cavity, bipolar cautery, dorsal lithotomy, fallopian tubes, fimbriated ends, fulgurated, laparoscope, uterus, distal, trocar, tubes,
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