Operative Report Sample:

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OPERATIVE REPORT

DATE OF OPERATION:  02/23/12

PREOPERATIVE DIAGNOSIS:
1. Pterygium, visually significant right eye.

POSTOPERATIVE DIAGNOSIS:
1. Pterygium, visually significant right eye.

OPERATIVE PROCEDURE:
1. Ocular surface reconstruction with amniotic membrane graft, right eye.

SURGEON: Dr. Smith
ASSISTANT: OR scrub nurse.
ANESTHESIA: MAC.
SPECIMEN SENT: None.
ESTIMATED BLOOD LOSS: Pterygium of the right eye.

JUSTIFICATION:  Subjective growth of corneal lesion and decreased vision in the above noted eye with chronic inflammation subjectively noted. Preoperatively all risks, benefits, general considerations and alternatives regarding the above noted surgery have been explained by myself to the patient including possible loss of vision, infection, double vision, recurrence, the need for additional surgery and the potential loss of the eye.  The patient has acknowledged understanding and has preoperatively signed the informed operative consent. Advised of all potential ramifications of surgery the patient desires to undergo the above noted surgery. 

PROCEDURE:  Anesthesia was administered without complication.  An oculopress was placed over the eye for an appropriate duration.  Prior to the actual surgical procedure a time out was undertaken with the patient present on the Operating Room table.  The surgeon, anesthesia provider and circulating nurse confirmed the patient’s name, operative side, operative site and the exact procedure to be performed.  The patient was prepped and draped in the usual sterile fashion. 

A wire lid speculum was used to open the eyelid.  Two drops of Betadine 5.0% was placed on the eye for 1 minute.  The ocular surface reconstruction was begun by removing the pterygium.  A 57 blade was used to excise the pterygium in a lamellar fashion. The base of the pterygium was removed using a Westcott scissor.  Cautery was used to obtain hemostasis.  It was difficult to dissect the plane of the pterygium as there was diffuse corneal scarring.  The stroma was scarred, as was the limbal area.  Mitomycin-c 0.25 mg per ml was placed over the bare sclera for 30 seconds and the eye was copiously irrigated with several bottles of BSS.  The amniotic membrane graft was placed over the area and cut to the approximate size. Fibrin glue was used to adhere the amniotic membrane graft over the area of bare sclera.  There were no complications.  The eye was lightly pressure patched and shielded, after placement of a contact lens, subconjunctival injection, and antimicrobial ointment.  The patient was brought to the Recovery Room without incident. Preoperative study results, ramifications thereof were explained to the patient and a copy of the same was given to the patient.  The patient was told to see the primary care physician over the next 48 hours with a copy of the same preoperative study results. The patient will be seen by me in 24 hours.  The patient is given a postoperative instruction sheet and told to call me day and night for any reason whatsoever.