..ceCauc a s ian

Phone

Ph on e

H OEIi

Wor k PhonQ

Ph one

Insured 's IO No .

'l'ypQ of AnQ.\lthQ.1s

ANES Gen e r al

Aced-

Author ization jcc .

Spouse

Group No.

Insu r e d'lI ID No ..

Au thor i zat i on No .

Group No.

Accid&n t Date :

Sel f

,~

M

DOB

Aq.62

Empl oy e r

Wor k Phone

Ci ty , St.a ee , Zipcodli

City,Sute,Zip Code

llurg8 0n N~ and No.

PARTIAL,

etcmec n,

WC File , :

PhonQ

R.Cle tiotl4h.ip t o CVtuOant o;:-'Address

I nlluroo'li Employe r Address

City,State ,Zip Code

I n s u r ed ' s Empl oye r Addres s

Bi r thdate

Patient:MRN:DOB :

Pa tient R. lationship t o Insured:I neu r ed ' . NlllIle

Patient Relat i onsh ip to Emergency Contact ;Addrea ll

Patient Relationship t o Insur ed: Se l tInsur ed'S Name

Soc:ial Secur1.ty NO. •E•••P.'.o'•••r•••••••••••••••

AddJ:IiSS

PA'rIENT INFORMATION:Na.e (Last, Fi r s t , Middle )

Sooi-ll~ Secur1.ty No . H.a..J:1.t:a l StatusM

SEC ONDARY INSURANCE:

Insurer

Zn aured'a Empl oyer

I n s uranca Rep/Adjustar

WORK COMP: Work Re lat ed: ( J

I nsured's Emp loyer

PRIMARY INSURANCE:InSurer

Phone :

EMERGENCY CONTACT:

Name (Las t, Firs t )

Be low to be completed b y Admi ssi ons Of f ice

Address

GU1\R1INTOR' i?;l<tientN_Q {LaAt ,F.i r a t ,Midd..h'"

Pri~ry Di a gno s i s (Code)Neoplasm of unce rtain behavior ofPrilllary Pr ocedu.r. (Coo.)LAPAROSCOPY , SURGICAL ; COLECTOMY,

Secondary ProcG'ldurQ

SURGERY INFORM1I.TION :

n..tQ o f Surgary

Encounter:DOS:Physician:

Patient:MRN :DOB:

CliN ICAL INFORMATfON

. : Anvnended tolooudeadditional information.

::.URGICAl PATHOlOGY REPORT

UIAGNU::'I:>

SPECIMENS;COLON

GROSS DESCRIPTION:Submitted isa previoustyopened right colon and attached terminal JlellTl, thespecimen measuring20 em in length &rid up to7,5em In drcurnhlrence. The termlrllllileum meaaUf.. 5.0emIn lengthendh.. lin unremefl<at)/e muco&al surface, Smalldel1cal1 metallic suturK arl ldentlfll d at the margin omcl n sectlonld; similar staplllSarl encountered onsectioningtllrougll thldistal colonic margin. Thecolon mucosa Isalsounremarkable but comins twoareas of surgical tattooing, the smallerIdentified 2.11 em fromItl!l dIstal marginandmeasuresOYeran areaOf1 .~ J( 1.!5 an . The larger measures3.0 x 2.0 em andIsIdeMJftld 4.6 ern fnYn 1Mdlltal margin. There areno definitive areas of noc1Jlarltt or rMldullI pl'llypllon IM pd on. Seet!onlngreveals bluishtalloo staining r:llhe underlyingsUbmucosa WithoUt abnormaHtlas. A second fragmentof mucosal tissueIsIdenllfled measures 4,0 II 2.0x 1.1em. A small punetMe n a al' IILKgleallMtooing Is noted onthe mucosal surface andmea l Ll'M 0.5 ernIn allmetlr, Thl ,. arl nodtmonslrable I4tsIOIlI to~e mucosal surflce. SedIonlngreve.11 lrl,..marublfJtissueWIthoUt evidence a nodUlarrty ortllnefactlons. The vermlrorm appendIX Is attached In tile usual location and measures4.1emIn lenlJ&l. Tt1Il SlIl'l:l&a1sl.Jl1ace IS smcot/'l andglllllenlngand overlies a regular Il'lUSGUlar wall andpatent lumen.RlIprl8llntatlve SIlc:tlOM are l ubmMed In eightcassettes as follows:A · pl'OlClmal anddlstaISUrglC3! margin; ,B-e •smaller surglcallattooed area;D-F • largersurglcel tellOoed I rel!:a· liBd iDns from !heGep&rlllely submitted fragment of tissue;H·appemb.

AMFNDtJiEttT :"I:L. I lu rl

APpeNDIX WIlli NO DIAGNOSTICABNORMALme8.

SEPARATE SEGMENTOF SMALLBOWELIDENTIFIED WITH NODIAGNOSTIC ABNORMAL.ITIES.

RIGHT COLON AND TERMINAL ILEUM, RESECTION:TWO DISTINCT AREAS OF SURGICAl TATIOOING IDENTIFIED, NEGATIVE FOR RESIDUAL POLYPS.FOCAL EPITHELIAl MISPLACEMENT IS IDENTIFIED. NEGATIVE FOR MALIGNANCY.

ADDr."DU II ~

AflI rdewNionoIll1e oeM " iltlDr._ h 1rQ. Ij). cimltl "n tHl'II~eted Ilo"IlI ¥I~ we. rTlI!lI3ekIiOeI'l;fy . PGlyph'nBll8 killi oro. A1t1ouoh •ptdunCWlt8d polyp wBi ldentil".adbelween I!letwo 11'8&1 d~ IW'Idonmictllllcopic .v~llli.", ~ 1ilo'lil'l1O b••~noult\lld hytIwpJul!c poI\'P.hll'8j. flD ... id. .... cf _ nam-l"", lniD''''''~""'d:k:>1. an rroJtfIl••ddillOl'IlII lIctoo8~1lll1lA llJIlmillld •• bIoeka J, J lW1d K, COrre lation~ IUDIlIII!Io:l.

CLINICALINfORIllA.TION:UNCl;RTAIN COLON POLYPS

11I!III!I....------.1

Encounter:DOS:

a Yes

' DA

• 5 E

u..-l,- k-v-, <.

<:...ss" l DV\.::> s;:......,::,~.

lLl-

f AM tt X ANESTtt . COMPLICATION!l:

S-' " I n f

OPERATION PROPOSED

PREVIOUS ANESTHETICS AND COMPLICATIONS:

HGB: IY " AllERGY

HCT: ,", .S:'WBC: c;.. r uuax a Yes 0 NoPtr. f ood a Yes a No

DRUG THERAPY (E.G.. STEROIDS, TRANQUILIZERS, ANTIHYPERTENSIVES; DIET PILLS):

Patient:

MRN:DOB :

PSYCHOLOGICAL STATUS SUMMARY & ANESTH. PLAN INCLUDING AGENTS AND TECHNIOUES

Pllrel\,siS ClY9$~ N<>rS& Risks 0iscuss6d : 'l'!"vefl 0 NoNeIHlIIT1lJ5C 0.:0 Yes No a MAC / 0 Epldural 0 Spinal a B1od<:

Seizures a Yell No

Psych HX a Yll$ No

GASTROINTEsnNAL (INCLU. HEPATIC)

Ntl.U6&/l D ves~ No HlIp;n!tis 0 Yes flJ No ASAClass :

HI~18I1iemb 0 V~Q No /, c!' 3

GER esO No

PRE-ANESTHETIC SUMMARY

HABITS

rceecce 0 Yes

Alcohol 0 Yes

sec. Drvg Use 0 Vee

Slgt\alll"

CENTRAl. VOUS SYSTEMCephIlIgitJ Q Ves No

Sy"",," DVM No

"""" O YM No

eVA OV" No

Polio D VM No

1 ~,!t<-Iy

) \17 ""c

CARDIOVAC, SVSTEM

Pacemaker 0 Y"s ~ No PECAO 0 Yes No

MI D Ves No

HTN ~yeo; 0 No

Aogina 0 Ves ~ NoMUrTn ll a Ves NO

CHF 0 Yeo; No

Palpitallons D Yes No

ENDOCRINE HEMATOPETIC

ThyrOOl D Yes gNo Bleeding Disorder

D.M. D Yes NOD VM ONO_.

Roo. D Ves No D VM O N<>

RESPIRATORY SYST eXR

reO V" rUR' D Yes No PE""'., a Y"s No

0<"'" . D Yes No

HEAD, NECK, MOUTH,EVES, AIRWAYS

""""" L_ D ves ~ Nomeocene D VD$ No

D9nturQS a Yes No

Partials D ves No

Caps 0 Yes No

TMJ D Yes DNo

Encounter:

DOS:Physician:

Encounter:

DOS:Physician:

Patient:

MRN:DOB:

OPERATIVE REPORT

PROCEDURE: The patient was taken to the operative suite and followinginduction of general anesthesia, was sterilely prepped and draped in routine fashion. 0.5% Marcainewith epinephrine was injected infraumbilical1y. A midline incision was then made on the lower portion ofthe umbilicus. The Veress needle was carefully inserted and approximately 3.5 liters of C02 gas wasused to insufflate the abdominal cavity to a pressure of 14 mmHg. The verese needle was removed.The Optiview trocar and scope were Ihen passed as a Single unit into the abdominal cavity. The scopewas then passed. There was no evidence of atrogenic injury to the bowel or vasculature. A second 5mm port was passed in the right upper mid abdomen under direct visualization after injecting local hereall the way to the peritoneum. A third 5 mm port was then passed in the right lower quadrant about fourfinger-breaths medial to the ASIS. This also was passed under direct visualization after injection localhere as well. The cecum was identified. There was tallooil19 noted just above the cecum. The cecumand the ascending colon were adherent to the lateral abdominal wall. These adhesions were then takendown and the peritoneal reflection was opened up using electrocautery. The colon was mobilizedmedially with blunt dissection and electrocautery and then moving to the ligature apparatus. Theterminal ileum was identified. We continued to mobilize up around the hepatic flexure at which time weidentified additional tattooing right at the hepatic flexure. We continued to mobilize the gastric commonligament off of the colon using the ligature instrument to the mid portion of the transverse colon. Thisallowed us to fully mobilize the colon so that we could gain access lntra-abocmlnally and lift it up out ofthe abdominal cavny. At this point we had converted a right upper quadrant trocar to an 11 mm port. Atthis time an incision was made, lengthening this 11 mm port incision through all layers including therectus muscle. The abdomen was entered. We had left a Babcock attached to the ascending colon.This was palpated and the ascending colon was then grasped and it and the cecum were lifted up out ofthe abdominal cavtty. The' site was chosen for resection of our terminal ileum and a rent was created inthe mesentery. A GIA WCl5 placed across this, clamped and fired. The staple lines were swabbed withBetadine. We placed a long silk suture on the proximal terminal ileum in the event that if it fell baCk into

t aparosccptcauy assisted right hemicolectomy.

25 cc.

General endotracheal.

unreeectabte polyp at the hepatic flexure of the colon withtattooing identified just above the cecum and at the hepaticflexure.

Unresectable polyp at the hepatic flexure of the colon.

PROCEDURE:

PREOPERATIVE DIAGNOSES:

PATIENT NAME:MR#:ADMIT DATE:PROCEDURE DATE:

ANESTHESIOLOGIST:

ANESTHESIA:

ESTIMATEDBLOOD LOSS:

ASSISTANT:

SURGEON:

POSTOPERATIVE DIAGNOSES:

Encounter;DOS;Physician:

Patient;MRN;DOB:

Page 2

Ihe abdomen, we could gain retrieval. The colon was then fully withdrawn up out of the abdomen untilwe were about 5 cm distal to the tattoo. The site was chosen for resection of the colon al this point. Arent in the mesentery was created. The GIA was placed across this, clamped, and fired. The staplelines were swabbed with Betadine. The mesentery was then taken down using the ligature instrument.The right colic artery was then ligated with 2-0 silk. The specimen was then placed on the back table.The small bowel was then approximated to the transverse colon with a serial muscular stitch of 3-0 silk.Lap sponges were placed around the wound. The additional fat along the colon was then taken downwith electrocautery so that we would have a nice area for anastomosis. The anti-mesenteric comer ofeach staple line was then excised. One limb of the GIA was placed in the colon and one in Ihe smallbowel. These were carefully placed in apposition, clamped and fired. The staple llne was hemostatic.The remaining rent was then reapproximated with an Allis. A PA-60 was placed across this, clamped,and fired and the redundant tissue was then excised. This likewise was swabbed with Betadine. Wehad a good two-finger opening within the anastomosis. I then moved to the back table and opened upthe specimen. He had one long stalked polyp near the tattoo mark, but I did not see any evidence ofbroad-based polyp. This appeared to be a bread-based polyp when I had observed his cotonoacopy aweek ago. I was qclte concerned that this might have been even further distal in the colon, so we movedback to our anastomosis and just distal 10 the anastomosis; I performed a colotomy incision measuringabout two inches in length. The colon was inspected. I did not Visualize any other polypoid lesions. Atthis point the colon was swabbed with Betadine. The rent was closed with a running 3-0 Chromic sutureand a Connell stitch. Interrupted 3-0 silk Lembert fashion were then placed. The staple line on ouranastomosis was also reinforced with Lembert stitches of 3-0 silk. The rent in the mesentery wasapproximated with a running 2-0 Vicryl. The bowel and transverse colon were then dropped back downinto the abdominal cavity. The incision was apcroxlmateo with a running 0 Vicryl in the posterior rectusfascia and peritoneum. This was followed by a running #1 Vicryl on the anterior rectus fascia. Theabdomen was reinsutt leted with C02 and we reinspected the abdomen and hemostasis was wellachieved. The anastomosis did not appear to be kinked. At this point the C02 was suctioned from theabdomen. The remaining two troears were removed. The subcuticular tissues at the bigger incisionwere reapproxlmated with 3-0 Vicryl followed by closure of the skin with a running subcuticular 4-0Monocryl. The two trocar incisions were approximated with subcuticular 4·0 Monocryl as well.Dermabond was applied. At th is point he had what appeared to be an ingrown hair with a chroniccellulitis at his lower abdominal fold. This was opened with an 1S-gauge needle and rightly cauterized.There were also two other ingrown hairs which were opened and lightly cauterized as well. The patientwas SUbsequently transferred 10 the recovery room in apparent satisfactory condition.

GROSS PATHOLOGY: This is a very pleasant 62-year-old male who presented witha polypoid lesion found on endoscopy. This could nOI be resected and so the decis-ion was made toresect this colon. We performed a laparoscopically assisted right hemicctectomy, There was apossibility of a slight herniation in the right groin, but other than this there was no other gross pathology.

Time

men Removed

oaie

e stimated Blood LOSS=",,g;;;;:"=>::;"""~======-l

Patient:MRN:DOB :

Anesthesia Ueed

.. !J..-Progress~ote~:,--~ .

- ---- - --- ---_ .

~,--------~__t

._--_._----_._~--~-------_.

Physician Post Operative I Discharge Note

o e..t10~duro 1dr~~::e~Eii~<-J:BL.tf2,;d;;..;;;?J;;, :

~ ..:~1¥~ n--;;f Anesthesiol

Surgeon Sig

Dischar e lnformanon;

Seconda Dia 110SIS:

Medications:

Diet:

Acfivity:

Smoking Cessation~iinlL.. Lb Yes .::::D=-:.:.'N:::::O-,=D;;;::,..-:..:N~OI:..:Ap.:J;;l:;p;;.:lic::::a::.:bl~e=_-====-_-==__= ==- -j

FOIIOW-!dP..;.,:_~ .

Condition on DisGha~fi!.e:

'Physician Signature