Radical Orchiectomy Operative Sample Report

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Right testicular tumor.

POSTOPERATIVE DIAGNOSIS: Right testicular tumor.

OPERATION PERFORMED: Right radical orchiectomy.

SURGEON: John Doe, MD

ANESTHESIA: General anesthesia via LMA.

COMPLICATIONS: None.

DRAINS: None.

ESTIMATED BLOOD LOSS: 5 mL.

INDICATIONS FOR OPERATION: This patient presents to the office with a six-month history of a rock-hard nodule in his right testicle. Tumor markers are unremarkable. We have recommended a right radical orchiectomy. Informed consent has been obtained.

DESCRIPTION OF OPERATION: The patient was placed on the operating table in the supine position. General anesthesia was administered via LMA. The right inguinal and scrotal areas were sterilely prepped and draped in the usual fashion.

A small inguinal incision was made and carried down through the subcutaneous fat to expose the external rectus fascia. This was opened along the length of its fibers to expose the genital branch of the nerve as well as the spermatic cord. The nerve was carefully dissected and retracted medially to preserve it. The spermatic cord was lassoed with a Penrose drain, which was then looped and tightened as a tourniquet.

Further dissection of the spermatic cord distally freed the testicle. The gubernaculum was sharply incised with electrocautery. Hemostasis was obtained throughout the procedure when needed with electrocautery and silk ties. When the testicle had been delivered, the proximal cord was dissected to the internal inguinal ring. The cord was then divided between three sets of clamps. The testicle was removed. The proximal spermatic cord was then tied with 0 silk free ties. A total of two ties were placed on each of the two vascular pedicles and one 0 silk tie was placed on the vas deferens. The proximal cord was then examined for hemostasis, and there was no active bleeding. One of the ties on the proximal cord was left fairly long for possible future use during a retroperitoneal node dissection.

The floor of the inguinal canal was then examined for hemostasis, and there was no active bleeding. The nerve had been preserved. The rectus fascia was then reapproximated using interrupted 2-0 silk sutures. The wound was then irrigated with sterile water. The subcutaneous tissue was reapproximated with a running 3-0 chromic. The skin was closed with staples followed by sterile dressings and Tegaderm. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition. Sponge and needle counts were correct x2.

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