Self Instructional Manual for Cancer Registrars - SEER - National ...

EXAMPLE
F14
OPERATIVE
REPORT
Service Gen. Surg Ward Name Hugh Gutzman Hosp. No. 000032
Sex Male Age 87 Race Black Date of Operation 9/27/91
Surgeon Polk N. See, MD
Anesthesiologist
Assistant A. Helpp, MD
AI Quiet. MD
Name of Operation
Exploratory Laparotomy
Pre-Operative Diagnosis Bleedin_ Stomach Cancer
Post-Operative Diagnosis Inoperable Stomach Cancer
Operation started 11:52 am Operation ended 12:30 pm
OPERATIVE PROCEDURE: Exploratory laparotomy
PROCEDURE
IN DETAIL:
With the patient supine and under endotracheal anesthesia, the entire abdomen and lower
chest was prepped with pHisoHex and saline and draped with sterile sheets in the usual
manner. Through an upper midline incision the peritoneal cavity was entered. Exploration
revealed a huge mass posterior to the 7th rib which was penetrating the stomach, apparently
causing the bleeding. This mass measured about 7 inches in diameter. It was fixed in the
retroperitoneal space and to the posterior part of the stomach. It also ascended into the
liver, and there were multiple liver metastases and multiple peritoneal metastases. A node
from the greater omentum was biopsied; frozen section reported a highly anaplastic
malignancy. The patient was inoperable. Through the gastrohepatic ligament the mass was
further exposed and two sutures of 2-0 chromic were placed in the mass, and a small wedge
biopsy was performed. The tumor was bleeding, and several sutures of 2-0 chromic
atraumatic and a piece of Sur_icel I was inserted; the bleeding controlled. The patient was
poorly prepared pre-operatively, and his condition has not changed.
Date dictated 9/27/91 Date transcribed 10/1/91
1Surgicel--Hemostatic
agent
169