Operation Notes
Operation Notes
Operation Notes
Transcriptionists
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left vallecular lesion.
POSTOPERATIVE DIAGNOSIS: Left vallecular lesion.
OPERATIONS PERFORMED:
1. Direct laryngoscopy with biopsy.
2. Rigid esophagoscopy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ANESTHESIOLOGIST: Jill Doe, MD
FINDINGS: A 1.5 cm spherical left vallecula/base of tongue lesion, which
was biopsied. There was a small left epiglottic cyst on the lingual surface.
There were no other lesions seen in the patient's oral cavity, oropharynx,
hypopharynx or larynx. There were no mucosal lesions seen on rigid
esophagoscopy. There was no palpable cervical lymphadenopathy or floor of
mouth lesions.
INDICATION: The patient is a (XX)-year-old lady who presents with a left
vallecula/base of tongue lesion noted on fiberoptic examination. Therefore,
direct laryngoscopy with biopsy was indicated. The patient was consented.
DESCRIPTION OF OPERATION: The patient was brought to the operating
room and positioned supine on the operating room table. After induction of
anesthesia, the patient's head and neck were prepped and draped in the
usual sterile fashion. The larynx was exposed with an anterior commissure
laryngoscope. There were no laryngeal lesions seen. Right epiglottic cyst
was noted. A left vallecula/base of tongue round lesion was noted, and
biopsies were taken with the cup forceps. Hemostasis was achieved with
epinephrine-impregnated cottonoid pledgets.
ANESTHESIA: General.
INDICATIONS: The patient is a very nice (XX)-year-old female with a
history of chronic hypertrophic adenotonsillitis with obstructive symptoms,
scheduled for surgery. The risks, benefits and possible complications were
discussed including bleeding, infection and soreness.
DESCRIPTION OF OPERATION: The patient was taken to the operating room in
the care of Anesthesia, placed in supine position, premedicated and given general
anesthesia, prepped and draped in a sterile manner. The mouth retractor was placed in the
mouth and hung from the Mayo stand in the usual fashion. The tonsils were found to be at
4+. The right tonsil was grasped with a hemostat. Mucosal incision made in medial border
of the anterior pillar, exposing the tonsillar capsule. Dissection continued near the tonsillar
capsule to the superior muscle until the tonsil was completely removed in a superior to
inferior direction. No bleeding was noted but a few areas were lightly cauterized with
suction electrocautery.
DATE OF OPERATION:
PREOPERATIVE DIAGNOSIS: Bilateral deafness.