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123 Main Street
Anytown, USA 56789
Patient Name: Betty Doe
This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The
procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated. She has requested this corrective repair be undertaken, and a consent was signed .
The patient was brought into the operating room and placed in the supine position on the operating table . An intravenous line was started, and sedation and sedation anesthesia  was administered IV after preoperative P.O. sedation . The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously .
The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked  for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.
The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000
Epinephrine for anesthesia and vasoconstriction . The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.
The face was prepped and draped in the usual sterile manner.  After waiting a period of approximately ten minutes for adequate
vasoconstriction, the previously outlined excessive skin of the right upper eyelid
was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery . A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed . The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit . A similar procedure was performed exposing herniated portion of the nasal pocket . Great care was taken to obtain perfect hemostasis with this maneuver. A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion . Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed  with a couple of interrupted 7 – 0 blue prolene sutures.
At the end of the operation the patientʼs vision and extraocular muscle movements were checked and found to be intact . There was no diplopia ,no ptosis , no ectropion . Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally,
The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.
The patient was released to return home in satisfactory condition.
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An operative report is a document that every surgeon must generate (be it typed or dictated and transcribed) for every surgical procedure that is performed.
The general outline is for a brief bullet point style introduction followed by a "indications" section followed by the actual description of the surgery performed.
Surgeons do this soon after an operation, think of it as a written play by play of the operatioin. The goal is to have a document in the patients record that allows any future doctor to know exactly what was performed. T
he operative report is also how a surgeon and hospital get paid for the procedures they perform.
The postoeprative diagnosis is the condition that the surgeon has determined after the surgery.
For example a preoperative diagnosis may be gunshot wound, but after the surgery the surgeon found out the spleen was lacerated so he or she adds this to the postoperative diagnosis. Its impossible to know that the spleen was lacerated before surgery so that is why it wouldn't be in the preoperative diagnosis.
Many times the postoperative diagnosis is the same as the preoperative diagnosis , sometimes it is different depending on the surgery type and what was found.
CPT - stands for current procedural terminology . This is a numerical code developed by the american medical association that allows surgeons to bill and categorize their surgeries. Close to all common surgeries have CPT codes that are constantly changing with time. It doesn't mean much to the patient as it is more for specifying the surgery for billing.
This is the person assisting the surgeon. This can sometimes be a certified surgical assistant (S.A.) or a surgeon in training such as a resident surgeon. The assistant does not perform the procedure but often helps with holding instruments and performing tasks that require more than one set of hands. They are an integral part of an operating team.
The sedation anesthesia makes the patient drowsy sometimes called twilight anesthesia. In this case the surgeon used Lidocaine ( a numbing medication) with epinephrine ( a medication to prevent bleeding) and injected it into the skin before the procedure. think of this like novocaine at the dentist.
Indications for procedure is a section of the operative report where the surgeon explains why the patient is having surgery. It often describes the condition and why it requires surgical treatment.
Sometimes, in this section, the surgeon will also discuss the conversations had with the patient prior to surgery regarding risks and benefits of the procedure. sometimes that conversation is documented in the office chart of the patient.
The anesthesiologist monitors your cardiac rate( heart rate), Blood pressure ( the pressure of blood in your body) and oxygen saturation ( a marker of how well you are breathing) . These measurements are done with specific monitors that you are hooked up to in the operating room. Sometimes you are awake when they are putting the stickers or blood pressure cuff on, that is normal.
Prepped and Draped - The importance of keeping a clean and sterile environment in the operating room is one of the most important aspects of safety. Surgeons may say it in different ways but cleansing and protecting the surgical field is done in nearly every surgery.
Prepped - this is how the skin is cleansed prior to surgery. the skin must be cleansed using a special soap or cleansing solution in order to clean any bacteria off the skin before performing the surgery.
Draped - this is the process of placing sterile surgical drapes or cloths to protect the area of surgery from contamination.
The concept of sterile prepping and draping goes back centuries and is one of the sacred traditions of safe surgical procedures.