Surgical Dictation Examples
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The surgical dictation serves several functions. The operative note clearly lists the date of surgery, the patient’s name and identification (medical record number), preoperative/postoperative diagnoses, surgeon and assistant(s), and the precise procedure(s) performed, including laterality. The type of anesthesia and concentrations of injected or applied topical anesthesia used are also documented. Any intraoperative complications are described. The model and details of any implanted materials (allograft or synthetic) and/or quantity of injected or applied pharmacotherapeutics (eg, duration and concentration of mitomycin C [MMC]) should be included, including serial numbers for implants if not carefully noted elsewhere. Some surgeons will begin the dictation by reiterating the risks, benefits, and alternatives of the surgical history or by providing a brief clinical narrative detailing the indications for the procedure.
In this section, we will provide examples of surgical dictations for commonly performed surgical procedures. In the interests of brevity, the dictations will be limited to surgical details, with our preferred template (Table D-1) given for the first procedure only. It should go without saying that the specific examples of procedures given here are just that, and the reader should refer to his or her training for the indications and alternatives for each procedure.
| Date of Surgery: | / / |
| Preoperative Diagnosis: | Uncontrolled glaucoma EYE (right/left) |
| Postoperative Diagnosis: | Uncontrolled glaucoma EYE (right/left) |
| Surgeon: | |
| Assistant: | |
| Operation Performed: | Trabeculectomy with mitomycin C (0.4 mg/cc) EYE (right/left) |
| Anesthesia: | Topical 1% lidocaine with monitored intravenous sedation |
| Complications: | None |
Indications of Procedure: Uncontrolled intraocular pressure despite maximum tolerated medical therapy.
Description of Procedure: Informed consent was obtained from the patient, at which time the risks, benefits, and alternatives were discussed, and all questions were addressed. The patient was identified in the holding area, and the operative eye was identified as the (right/left) eye.
The correct operative eye was confirmed and a single drop of tetracaine was applied to the eye. The eye was then prepped and draped in the usual sterile manner for ophthalmic surgery. A lid speculum was inserted. The patient was instructed to look down to infraduct the globe.
Topical 1% preservative-free lidocaine was subsequently applied to the superior conjunctiva. A superior limbal peritomy was created using non- toothed forceps and Vannas scissors, and 1% preservative-free lidocaine was injected into the subconjunctival and sub-Tenon’s space. The peritomy was then dissected posteriorly, medially, and laterally with mini-Westcott scissors. The sclera was then devascularized with broad strokes of a No. 69 Bea- ver blade, using 0.12 forceps to stabilize the globe. A No. 75 blade was then used to create a 50% thickness trapezoidal scleral flap. This was extended toward the limbus with a No. 69 blade. Cellulose sponges soaked with
0.4 mg/mL MMC were applied beneath the conjunctiva and held in place for 2 minutes. A wide diffuse application was achieved, and all of the sponges were subsequently identified and removed. Copious irrigation with balanced salt solution was performed. Two interrupted 10-0 nylon sutures were then pre-placed through the scleral flap. A corneal paracentesis was created with a No. 75 blade, which was then used to enter the anterior chamber through the base of the scleral flap. A Kelly–Descemet punch was used to create a 0.75-mm sclerostomy, and a broad-based peripheral iridectomy was performed. The pre-placed nylon sutures were then adjusted for appropriate flow, tied, and the knots were buried. The conjunctiva and Tenon’s fascia were then reapproximated to the limbus and tied in place with 4 interrupted 10-0 nylon wing sutures, the knots of which were buried. Intracameral balanced salt solution was injected, an elevated conjunctival bleb was observed, and no leaks were identified. The intraocular pressure (IOP) by palpation was reconfirmed to be approximately mid-teens. 1% atropine ophthalmic solution was instilled, followed by a fourth-generation fluoroquinolone antibiotic. The eyelid speculum was removed, and the eye was shielded. The patient was brought to the recovery area in excellent condition, having tolerated the procedure well without any complications.
Baerveldt Glaucoma drainaGe device With Patch Graft
The patient was given a retrobulbar block under intravenous seda- tion consisting of a 1:1 dilution of 2% lidocaine and 0.75% bupivocaine. The correct operative eye was confirmed, a single drop of tetracaine was applied, and the eye was prepped and draped in the usual sterile man- ner for ophthalmic surgery. A lid speculum was inserted. A clear corneal 7-0 Vicryl traction suture was placed at the 12 o’clock position, and the globe was infraducted. Topical preservative-free 1% lidocaine was applied to the conjunctiva. A 3 clock-hour conjunctival peritomy was created using the Westcott scissors at the superotemporal limbus. A sub-Tenon’s cannula was then used to deliver 1% lidocaine into the parabulbar and retrobulbar space through the peritomy. Hemostasis was achieved with gentle application of bipolar wetfield cautery. The Baerveldt 350-mm2 glaucoma implant was inspected, and balanced salt solution was injected into the tube tip using a 30-gauge cannula to ensure patency. Tenotomy muscle hooks were used to isolate the rectus muscles, and the Baerveldt implant was placed under the superior and lateral rectus muscles, taking care to avoid the separation of any muscle fibers. The implant plate was secured to the globe approximately 8 to 10 mm posterior to the limbus using 2 interrupted 9-0 nylon sutures with the knots buried. The tube was ligated with a single 7-0 Vicryl suture and confirmed to be watertight by injection of balanced salt solution. The tube was trimmed with an anterior bevel, and a 23-gauge needle was used to tunnel into a deep position in the anterior chamber from an entry 2.5 mm posterior to the limbus. The tube was inserted into the eye and confirmed to be in excellent position in the anterior chamber and secured to the sclera using a 9-0 nylon suture. Two tube fenestrations were created using the Vicryl needle. A pericardial patch graft was trimmed to the appropriate size, placed over the tube’s insertion and secured using several interrupted 7-0 Vicryl sutures. Conjunctiva and Tenon’s fascia were secured at the limbus using interrupted and running 7-0 Vicryl sutures. At the conclusion of the procedure, the anterior chamber was noted to be deep and well formed, the tube was in excellent position, the IOP by palpation was confirmed to be approximately mid-teens, and no leaks or buttonholes were identified. A subconjunctival injection of Decadron and gentamycin was administered in the inferior cul-de-sac. The lid speculum was removed, Maxitrol ophthalmic ointment was applied, and a pressure patch and protective shield were placed over the eye. The patient was brought to the recovery area in excellent condition, having tolerated the procedure well without any complications.
Limbus-based traBeculectomy With mitomycin c (retroBulBar Block)
The patient was given a retrobulbar block under intravenous sedation consisting of a 1:1 dilution of 2% lidocaine and 0.75% bupivocaine. After adequate anesthesia and akinesia were achieved, the patient was brought into the operating room. The operative eye was prepped and draped in the usual sterile manner for ophthalmic surgery. A lid speculum was inserted. A clear corneal 7-0 Vicryl traction suture was placed at the 12 o’clock position, and the globe was infraducted. The superior conjunctiva and Tenon’s cap- sule were elevated and then incised approximately 10 mm posterior to the limbus, and a tangential incision was created approximately 6 mm in length, taking care to avoid the superior rectus muscle and associated blood vessels. A No. 75 blade was then used to create a 50% thickness trapezoidal scleral flap, which was extended toward the limbus with a No. 69 blade. Cellulose sponges soaked with 0.4 mg/mL MMC were applied beneath the conjunctiva and held in place for 2 minutes. A wide diffuse application was achieved, and all of the sponges were subsequently identified and removed. Copious irrigation with balanced salt solution was performed. Two inter- rupted 10-0 nylon sutures were then pre-placed through the scleral flap. A corneal paracentesis was then created with a No. 75 blade, which was then used to enter the anterior chamber through the base of the scleral flap. A Kelly–Descemet punch was used to create a 0.75-mm sclerostomy and a broad-based peripheral iridectomy was performed. The pre-placed nylon sutures were then adjusted for appropriate flow, tied, and the knots were buried. An 8-0 Vicryl suture on a vascular needle was used to reapproximate the Tenon’s capsule and conjunctiva in a running and locking fashion. Intracameral balanced salt solution was injected, an elevated conjunctival bleb was observed, and no leaks were identified. The IOP by palpation was reconfirmed to be approximately mid-teens. 1% atropine ophthalmic solution was administered. The lid speculum was removed, Maxitrol ophthalmic ointment (neomycin and polymyxin B sulfates and dexamethasone ophthalmic suspension) was applied, and a pressure patch and protective shield were placed over the eye. The patient was brought to the recovery area in excellent condition, having tolerated the procedure well without any complications.
TraBectome and cataract extraction
The correct operative eye was confirmed, prepped, and draped in the usual sterile manner for ophthalmic surgery. Topical tetracaine ophthalmic solution was applied and a lid speculum was inserted. A 1.7-mm clear corneal incision was made at the 3 o’clock position using a metal keratome blade. Preservative-free 1% lidocaine was then introduced into the anterior chamber, followed by viscoelastic. A goniolens was placed on the cornea, and visualization of the angle was confirmed. The Trabectome was then introduced into the anterior chamber, and the tip of the Trabectome was inserted into Schlemm’s canal anterior to the scleral spur. Aspiration and ablation of the trabecular meshwork was thus performed in a clockwise direction for approximately 2 clock hours and redirected in a counterclockwise direction for approximately 1 clock hour. The trabectome was subsequently removed. Two clear corneal paracentesis incisions were made at the 7 o’clock and 11 o’clock positions using a No. 75 blade, and additional viscoelastic was introduced into the anterior chamber. A 2.75-mm keratome blade was used to enlarge the clear corneal incision through the prior Trabectome entry site. A bent cystotome needle and capsulorrhexis forceps were used to create a continuous curvilinear capsulorrhexis. Hydrodissection was performed using a flat 27-gauge cannula and balanced salt solution, and free rotation of the lens nucleus was obtained. Disassembly and removal of the lens was performed using standard chopping techniques with phacoemulsification. Residual cortical material was removed using bimanual irrigation and aspiration. The capsular bag was reformed with a viscoelastic and noted to be intact. An intraocular lens (IOL) with power + D, serial number, was placed into the capsular bag. Residual viscoelastic was removed using irrigation and aspiration. The temporal clear corneal wound and paracentesis incisions were hydrated using balanced salt solution. The corneal incision was closed using a single interrupted 10-0 nylon suture and confirmed to be watertight without leakage. The lid speculum was removed, and a fourth-generation fluoroquinolone antibiotic was placed. The eye was shielded. The patient was brought to the recovery area in excellent condition, having tolerated the procedure well without any complications.
Ex-PRESS Glaucoma device With mitomycin c
Topical 1% preservative-free lidocaine was applied to the superior conjunctiva. A superior limbal peritomy was created with nontoothed forceps and Vannas scissors. 1% preservative-free lidocaine was then injected into the subconjunctival and sub-Tenon’s space. The peritomy was subsequently dissected posteriorly, medially, and laterally with mini-Westcott scissors. The sclera was then devascularized with broad strokes of a No. 69 Beaver blade, using 0.12 forceps to stabilize the globe. Next, a No. 75 blade was used to create a 50% thickness trapezoidal scleral flap. This was extended toward the limbus with a No. 69 blade. Cellulose sponges soaked with
0.4 mg/mL MMC were then applied beneath the conjunctiva and held in place for 2 minutes. A wide diffuse application was achieved, and all of the sponges were subsequently identified and removed. Copious irrigation with balanced salt solution was performed. Two interrupted 10-0 nylon sutures were pre-placed through the scleral flap, and a corneal paracentesis was created with a No. 75 blade. The anterior aspect of the scleral spur was identified at the base of the flap, and a 26-gauge needle was used to enter the anterior chamber parallel to the iris plane. The needle was marked with a marking pen prior to insertion to facilitate identification of the entry site. The Ex-Press shunt was then placed in the newly created incision. The Ex- Press shunt tip was judged to be in a good position in the anterior chamber, and the back plate was flush with the scleral bed. A diagonal 10-0 nylon flap suture was then placed in each corner of the scleral flap. Balanced salt solution on a cannula was injected into the anterior chamber through the paracentesis, and steady flow was observed through the flap.
The conjunctiva and Tenon’s fascia were then reapproximated to the limbus and tied in place with 4 interupted 10-0 nylon wing sutures, the knots of which were buried. Intracameral balanced salt solution was injected, an elevated conjunctival bleb was observed, and no leaks were identified. The IOP by palpation was reconfirmed to be approximately mid-teens. 1% atropine ophthalmic solution was administered, followed by a fourth-generation fluoroquinolone antibiotic. The eyelid speculum was removed, and the eye was shielded. The patient was brought to the recovery area in excellent condition, having tolerated the procedure well without any complications.
Ahmed Glaucoma valve ImPlantation With Patch Graft
Following initiation of IV sedation and topical application of tetracaine and betadine ophthalmic solution, retrobulbar anesthesia was induced with a 4-cc injection of 1% lidocaine and 0.75% bupivacaine mixed in a 50-50 concentration. The (right/left) eye was then prepped and draped in the usual sterile ophthalmic manner, and a lid speculum was applied.
Using Westcott scissors and nontoothed forceps, a conjunctival peritomy was created in the superotemporal quadrant. Blunt dissection was performed between Tenon’s fascia and the sclera to expose the bare sclera between the superior and lateral rectus muscles. A muscle hook was then used to identify the superior and lateral rectus muscles. Balanced salt solution on a 30-gauge cannula was then used to “prime” the silicone Ahmed FP7 valve, demonstrating its patency and ability to provide resis- tance to balanced salt solution. The plate was then inserted between the superior and the lateral rectus muscle over the bare sclera approximately 8 mm posterior to the limbus. Using 8-0 nylon, the valve was sutured to the sclera through the plate’s anterior suture holes. The tube of the valve was then laid flat on the cornea and cut with Westcott scissors in a bevel- up fashion to allow several millimeters of tube tip in the anterior chamber following insertion. A corneal paracentesis incision was then created inferotemporally. A 23-gauge needle was then inserted 2 mm posterior to the limbus and tunneled into the deep anterior chamber parallel to the iris plane at the 12 o’clock position. Using Kelman–McPherson tying for- ceps, the tube of the Ahmed valve was inserted into the anterior chamber, which was reformed and repressurized using balanced salt solution. The tube was then secured in position using a 10-0 nylon horizontal mattress suture. An approximately 4×4-mm sheet of pericardial patch graft was then furnished to cover the tube over its limbal insertion and posteriorly. The pericardial patch was sutured into place with 2 8-0 Vicryl interrupted sutures. Conjunctiva and Tenon’s capsule were then reapproximated to the limbus using 8-0 Vicryl interrupted wing sutures. A subconjunctival injection of Decadron and gentamycin was administered in the inferior cul-de-sac. The lid speculum was removed, Maxitrol ophthalmic ointment was applied, and a pressure patch and protective shield were placed over the eye. The patient was brought to the recovery area in excellent condition, having tolerated the procedure well without any complications.
