OR: Operative Note

OPERATIVE NOTE PATIENT: John Doe DATE OF BIRTH: 01/15/1970 MEDICAL RECORD NUMBER: 123456789 DATE OF SURGERY: 08/26/2024 PREOPERATIVE DIAGNOSIS: - Bladder Cancer POSTOPERATIVE DIAGNOSIS: - Bladder Cancer PROCEDURE: - Radical Cystectomy - Ileal Conduit Urinary Diversion SURGEON: - David Canes, M.D. ASSISTANT: - Jane Smith, PA-C ANESTHESIA: - General Anesthesia IV FLUIDS: - 2000 mL Lactated Ringer's Solution ESTIMATED BLOOD LOSS: - 500 mL DRAINS: - 1. Jackson-Pratt drain in the pelvic cavity - 2. Ureteral stents COMPLICATIONS: - None SPECIMENS: - 1. Bladder - 2. Prostate INDICATIONS: The patient is a 53-year-old male with a history of muscle-invasive bladder cancer. After discussing the diagnosis and treatment options, including the risks and benefits of surgery, the patient elected to proceed with a radical cystectomy and ileal conduit urinary diversion. The risks, benefits, pros, cons, side effects, and alternatives of the procedure were reviewed and he wished to proceed. Common risks such as infection, bleeding, and injury to surrounding organs were reviewed and questions were answered. PROCEDURE IN DETAIL: The patient was brought to the operating room and placed under general anesthesia. After proper positioning and sterile preparation, a midline incision was made. The bladder was mobilized and removed along with the prostate. An ileal segment was isolated and used to create a conduit for urinary diversion. Ureteral stents were placed, and a Jackson-Pratt drain was inserted into the pelvic cavity. Hemostasis was achieved, and the incision was closed in layers. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. PLAN: - Monitor for signs of infection - Follow-up in 2 weeks for stent removal David Canes, M.D. 08/26/2024