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

EXAMPLE
F16
OPERATIVE
REPORT
Service GU Ward Sex Female Age 61 Race Black Date 12/15/91
Surgeon A. Tieoff, MD Assistant A. Sist, MD Anesthesiologist Q. Tee, MD
Name of Operation
Exploratory lap with ligation of R ureter
Pre-Operative Diagnosis Adenocarcinoma R kidney with hematuria
Post-Operative Diagnosis Adenocarcinoma R kidney with severe hemorrhage
Operation Started 11:15 am Operation ended 11:42 am
CLINICAL HISTORY: This 61-year-old black female was admitted to Urology with
severe bladder hemorrhage. Physical examination revealed a right flank mass. On IVP
the patient had poor to no function. At cystoscopy the patient had a large dilated orifice
on the right side with blood gushing through. The patient required 5 units of blood to
replace blood loss prior to this (her hematocrit was only 21%). Also pre-operative
evaluation revealed the patient had what appeared to be bilateral pulmonary metastases
from a hypernephroma and possible metastasis to the right hip. Because of the patient's
blood requirements, it was felt that ligation of the ureter might help to tamponade the
bleeding.
OPERATIVE FINDINGS: Removal of the tumor was impossible because of its size
with probable fixation to the diaphragm and great vessels.
PROCEDURE IN DETAIL: The patient was placed in the supine position, the
sand-bag was placed under the right flank, the skin was prepped with ether and betadine
and sterile drapes were applied in the usual manner. A transverse incision was made
extending from the lateral border of the rectus muscle to the anterior superior lilac spine
with the combination of sharp and blunt dissection. The muscles were divided, split, and
the retroperitoneal space opened at the anterior-superior iliac spine level. Bowel
contents were retracted posteriorly.
The peritoneum was not opened and the ureter was identified as it crossed the pelvic
brim. It was markedly dilated and had a bluish appearance. The ureter was ligated with
zero-silk at 2 levels.
The patient tolerated the procedure well. A small drain was left in the area of
dissection. The muscles were approximated with interrupted zero-chromic, the
subcutaneous tissue with 2-0 plain, and the skin was closed with 3-0 silk.
Date dictated 12/15/91 Date transcribed 12/16/91
Patient Name Tessie Sicksack Record Number 000034
179