Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 5

Description: Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Biliary colic.

POSTOPERATIVE DIAGNOSIS: Biliary colic.

PROCEDURE: Laparoscopic cholecystectomy.

ANESTHESIA: General with endotracheal intubation.

The procedure was explained to the patient and consent was obtained.

DESCRIPTION OF PROCEDURE: He was taken to the operating room, placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. Marcaine was injected into the umbilicus. A small incision was made. A Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg and then a 12-mm VersaStep port was placed into the umbilicus. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope. Another 5-mm port was placed just anterior to the mid-axillary line and just subcostal. The gallbladder was grasped by its infundibulum, pulled inferolaterally. The cystic duct was thereby splayed out. It was bluntly dissected, and 2 clips were placed proximally and 1 distally; and it was divided. The cystic artery was then encountered, and 2 clips were placed proximally and 1 distally; and it was divided. The gallbladder was then taken off the hepatic fossa using electrocautery and placed in an Endocatch bag and removed from the umbilicus. The fascia at the umbilicus was closed with an interrupted 0 Vicryl suture. I irrigated out the abdomen. There was no bile leak and no bleeding. The ports were then removed. The skin of all incisions was closed with a running Monocryl. Sponge, instrument and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications.

Keywords: surgery, veress needle, gallbladder, laparoscope, laparoscopic examination, endotracheal intubation, laparoscopic cholecystectomy, biliary colic, abdomen, cholecystectomy, endotracheal, umbilicus, laparoscopic,
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