Documentation Templates

This is a [age] year old [gender] who presents on [date] as a [p1/p2/consult] after [mechanism]. Trauma bay course remarkable for [course]. Injuries (by system) Head: [] Spine: [] Chest: [] Intraperitoneal: [] Retroperitoneal: [] MSK [] Consults: [] # Neuro GCS in trauma bay: [] GCS on arrival: [] Sedation: gtt: [] / sch: [] / prns: [] # Pain: gtt: [] / sch: [] / prns: [] # Cardiovascular MAP: [] HR: [] Pressors: [] Trops: [] EKG: [] ECHO: [] # Respiratory Vent settings: [] ABG: [] CXR: [] # GI/Nutrition Diet: [] NGT/OGT: [] Bowel reg: Miralax BID # Renal Fluids in trauma bay: [] Monitor UOP Lab schedule: [] Foley: [] Lactate: [] BMP: [] Mg/Phos: [] Fluid status: [] IVF: [] # Hematology Tranfusions in trauma bay: [] Hgb/Hct: [] Platelets: [] # Infectious Temp: [] WBC: [] Antibiotics: [] # Endocrine BG on arrival: [] Insulin: [] POC BG Schedule: [] # MSK PT/OT # PPx DVT: [] GI: [] # Access [] # Disposition TICU

Assessment: Patient is a [age] year old [sex] with a history of [diseases] who is now s/p [procedure]. Post op course has been [course]. Plan: # s/p [] transplant - immunosuppression per transplant medicine team # HTN - [] # Additional medical problems Diet: [] IVF: [] DVT ppx: SQH GI ppx: [] Bowel reg: []

This is a [age] year old patient with a history of [diseases] who was diagnosed with [diagnosis] and is now s/p [procedure] on [procedure_date]. Recovery has been [summary]. Problem list (plan by problem) 1. [] Diet: [] IVF: [] DVT: [SQH/LVX/held with reason] Bowel reg: [] Abx: [] Activity: [Out of bed with assistance] Dispo: [floor/ICU/discharge/transfer]

General: NAD Head and neck: normocephalic Respiratory: unlabored Cardiovascular: WWP Abdomen: [] Extremities: non-traumatic Psych: normal affect Neuro: non-focal

General: No fevers, chills, unintentional weight loss HEENT: No visual changes, dysphagia CV: No chest pain, no heart palpitations Pulmonary: No cough, no shortness of breath GI: See HPI GU: No dysuria, No hematuria MSK: No arthralgias, No myalgias Neurologic: No syncope, No extremity weakness, No paresthesias Skin: No rash, no ecchymosis Psychiatric: No increased anxiety, No worsening depression

General: [] Head and neck: [] Respiratory: [] Cardiovascular: [] Abdomen: [] Extremities: [] Psych: [] Neuro: []

General: critically ill, sedated Head and neck: ETT in place and [ogt/ngt] in place Respiratory: intubated, [vent mode] [vent settings] Cardiovascular: [HR] [map] [pressors] Abdomen: [] Extremities: [] Psych: unable to assess Neuro: []

This is a [age] year old [gender] who presents with [complaint]. Differential diagnosis includes [ddx]. # []

This is a 40 year old male who presents on [date] as a P2 after non-helmeted motorcycle vs car. Trauma bay course: GCS: 15 Blood/fluids: 1L LR Primary survey: unremarkable Secondary survey: right ptx Procedures: right open chest tube Injuries (by system) Head: SAH Spine: Chest: right ptx Intraperitoneal: Retroperitoneal: MSK: road rash right shoulder, fractured left thumb Consults: NSGY Ortho # SAH GCS15, neuro intact NSGY following - ticu admission - repeat 24hrs - q1 neuro exams # right ptx CT to -20 daily CXR # road rash Bacitracin BID # fracture left thumb Ortho consulted - no intervention - follow up outpatient 2 weeks after discharge. Call 867-5309 for apt. # HTN On metoprolol at home hold metoprolol for now Diet: Regular IVF: None Pain: ATC tylenol, PRN morphine GI ppx: none DVT ppx: LVX Activity: Up ad lib Dispo: Floor Anticipated discharge dispo: Home

# Resident To-do: [ ] Make sure that all post op admits have the post op labs drawn and CXR as ordered in the Kidney post op order set [ ] Ensure that the post op renal US is preformed and update the surgeon on the results. [ ] Review the summary of the patients past medical history can be found in the Transplant medicine preoperative clearance note. [ ] Ensure that all comorbid conditions are listed under the appropriate system [ ] Complete a medicine reconciliation with the help of transplant surgery. [ ] Monitor UOP and update trauma surgery if there is a sudden decrease in UOP. [ ] Monitor SBP closely and update trauma surgery and/or medicine if you are considering starting a drip. [ ] Monitor BMP closely, some patients may need treatment for electrolyte derangements or dialysis. Make sure to discuss with transplant medicine. This is a *** year old *** with a past medical history of *** who presents to the TICU s/p DDKT on ***. # Neuro Sedation: None Pain: Tylenol 650 PRN, Oxycodone 5/10 PRN, Dilaudid PRN # Cardiovascular MAP: *** HR: *** HDS Hydralazine 20 mg IV q4h PRN SBP >170. Nofity resident if more than 3 doses given. Labaetolol 10 mg q15m PRN SBP >180. Nofity resident if more than 3 doses given. # GI Diet: *** Zofran PRN Bowel regimen: Cater oil 60 mL PO x1, bisacodyl EC 10 mg PO BID, Bisacodyl Supp 10 mg PR daily PRN, Senna/Doc BID. # Renal S/p DDKT on *** Foley catheter BMP on arrival: *** Post op renal US: *** D51/2NS @ 50 Replace UOP with 1:1 fluids Transplant medicine following CMP q6h x4 #Hematology Preop Hgb: *** Intraop blood loss: *** Hgb on arrival: *** Platelets: *** PT/INR: *** aPTT: *** CBC q4h x6 # Infectious WBC: *** Transplant medicine following Ppx abx: Valcyte, Bactrim Immunosuppressents: Thymoglobulin in AM, Solumredrol in AM, Cellcept BID, Prednisone 5 mg daily on POD2, Tacrolimus BID # Endocrine BG on arrival: *** Insulin: *** POC BG schedule: *** # MSK No skin breakdown Bendryle PRN for itching # Prophylaxis SCDs SQH Pepcid # Access Arterial line: *** PIVs # Disposition TICU

May resume regular diet as tolerated. Remain upright while eating. Encouraged to take small bites and chew thoroughly. Use over the counter stool softeners & laxatives as needed for constipation.

General: supine, well nourished HEENT: trachea midline. normocephalic Pulmonary: unlabored breathing Cardiovascular: RRR Abdomen: [] Neuro: moves all 4 extremities

General: supine, NAD HEENT: trachea midline. normocephalic Pulmonary: unlabored breathing Cardiovascular: RRR Abdomen: [] Neuro: MAE

General: no acute distress Respiratory: Unlabored breathing on [] Cardio: RRR Abdomen: soft, non-distended, non-tender Extremities: [] Psych: Normal affect Vascular: RLE: Femoral: [] Popliteal: [] PT: [] AT: [] DP: [] Skin: [] LLE: Femoral: [] Popliteal: [] PT: [] AT: [] DP: [] Skin: []

This is a [age] year old [gender] who presents with [complaint]. Differential diagnosis includes [ddx]. # [] Diet: [] IVF: [] Pain: [] DVT ppx: [] GI ppx: [] Activity: [] Dispo: []

This is a [age] year old [gender] who presents on [date] as a [p1/p2/consult] after [mechanism]. Trauma bay course: GCS: [GCS] Blood/fluids: [] Primary survey: [] Secondary survey: [] Procedures: [] Injuries (by system) Head: [] Spine: [] Chest: [] Intraperitoneal: [] Retroperitoneal: [] MSK [] Consults: [] #[first problem/injury - problem based assessment and plan] [] Diet: [] IVF: [] DVT: [SQH/LVX/held with reason] Bowel reg: [] Abx: [] Activity: [Out of bed with assistance] Dispo: [floor/ICU/discharge/transfer] Anticipated discharge dispo: [home/rehab]

May continue full liquid diet as tolerated. Remain upright while eating. Encouraged to take small bites and swallow slowly. Your diet will be advanced if appropriate upon your first follow up visit to clinic. Encouraged to use stool softeners as needed while taking narcotic medication.

Day to day activity, no heavy lifting, pushing, pulling > 10lbs, no driving while taking opiate medications

OK to shower, no hot tubs, baths, pools, submerging incisions under water until completely healed. Monitor for redness, increased or changed drainage or swelling around incision sites. No lotions creams or oils over incision sites. Remove chest tube dressing prior to showering, replace with gauze and tape or bandaid if continues to drain fluid. Fluid may continue to drain for a couple of days post-operatively especially with coughing/sneezing or bearing down. Fluid may be orange, red, pink or yellow. If fluid looks milky or thick please call.

Dissection was carried up to the level of the lower border of the right bronchus intermedius. 11R lymph nodes were excised and sent for permanent pathology.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, boney areas padded, sequential compression devices applied to the bilateral lower extremities and secured with straps. General anesthesia was induced and patient was intubated without issue.

Attention was turned to the inferior pulmonary ligament. This was released with electrocautery to the level of the inferior pulmonary vein. Level 9 lymph nodes were sampled and sent for permanent pathology.

The patient was placed in the [left/right] lateral decubitus secured with straps, beanbag and all bony prominences padded. Bronchoscopy was again performed confirming appropriate location of the double lumen ET tube.

General anesthesia was induced the patient was intubated with a double-lumen ET tube. Bronchoscopy confirmed appropriate position of the tube.

A safety check was performed before induction of anesthetic and all were in agreement of patient and procedure and side.

New clinical problem: [] Case summary: [] Disease-specific elements: [] Other PMH: [] Other SH: [] Reason for presentation: []

She/He denies recent illness, fever, chills, SOB, cough, weight loss, hemoptysis or night sweats. She/He is no longer smoking.

Plan: dc NGT UGI this AM; results pending possible clear liquid diet with plan to transition to full liquid for discharge IV pain meds; transition to oral once able bowel regimen once able to take oral possible discharge home if tolerates diet and no concerns on UGI

Continue to encourage coughing and deep breathing, incentive spirometer 10x/hr Multimodal pain control with oxycodone, dilaudid, tylenol and lidocaine patches CT to -20cm suction Duonebs and mucomyst q4h for increased secretion clearance Metoprolol for afib ppx DVT ppx with LVX Continue home medications OOB as tolerated, PT/OT for strengthening/discharge CXR in AM or sooner if needed

Wipe down with water and wash cloth being careful to avoid chest tube site, can shower with chest tube dressing completely covered with transparent dressing, however, chest tube dressing needs to be changed after shower.

The posterior pleural was opened dissection was opened and dissection carried into the subcarinal space and level 7 lymph nodes were excised.

General: NAD Head and neck: normocephalic Respiratory: unlabored on [room air/nc/etc] Cardiovascular: WWP Abdomen: non-distended Extremities: non-traumatic Psych: normal affect Neuro: non-focal

Return to ER/ATC with fever > 101, chills, worsening chest pain, shortness of breath, abdominal pain, nausea, vomiting, redness/warmth from incision sites, purulent drainage from incisions, increased swelling or pockets of air in chest/neck. Pain management: Use tylenol (acetaminophen) 650mg every 6 hours as needed for pain. You can alternate with Ibuprofen 600mg every 6 hours as needed for pain and use oxycodone (see prescription orders) for breakthrough pain.

This is a *** year old *** who presents on *** as a *** after ***. Patient has a history of *** Trauma bay course remarkable for ***. Injuries (by system): Head: *** Spine: *** Chest: *** Intraperitoneal: *** Retroperitoneal: *** MSK: *** Consults: *** # Neuro GCS: Sedation gtt: *** sch: *** prns: *** Pain gtt: *** sch: *** prns: *** # Cardiovascular MAP: *** HR: *** Pressors: *** Trops: *** EKG: *** ECHO: *** # Respiratory Vent settings: *** ABG: *** CXR: *** # GI Diet: *** NGT/OGT: *** BM: *** Bowel reg: *** # Renal UOP: *** Foley: *** BMP: *** Mg/Ph: *** IVF: *** Free water flushes: *** Fluid Status: *** Diuresis: *** # Hematology Hgb: *** Platelets: *** # Infectious Temperature: *** WBC: *** Cx Blood Sputum Wound date # Endocrine Blood glucose range last 24 hrs: *** Insulin: *** Insulin requirements in last 24 hrs: *** POC BG Schedule: *** # MSK PT/OT # PPx DVT: *** GI: *** # Access *** # Disposition TICU

Attention was turned to the area just inferior to the azygous vein and the right mainstem bronchus and level 10R lymph nodes were excised.

Next attention was turned superior to the azygous in the paratracheal space and level 4R lymph nodes were excised and further superiorly level 2R lymph nodes were excised.

Patient was met in the preoperative holding area, consent was confirmed and all questions were answered. Patient was transported back to the operating room placed on the OR table in the supine position, bony areas padded, sequential compression devices applied to the bilateral legs and secured with straps. General anesthesia was induced, and patient was intubated without issue. [Abx] was given prior to the procedure. The abdomen was prepped and draped in normal sterile fashion and a timeout was done and were all in agreement. The abdomen was accessed in the left upper quadrant with 5 mm optical trocar technique. The abdomen was insufflated to 15 mmHg there was no visceral injury upon entry. A 12 mm port was placed in the supraumbilical area as well as a 5 mm left lower quadrant port both under direct vision without visceral injury. The abdomen was surveyed, the small bowel pushed aside, and the cecum and the right colon were gently moved medially revealing the appendix. It was noted to be [appearance]. [Accessory ports] [PICK ONE] The mesoappendix was divided with the harmonic scalpel to the base of the appendix. The appendix was divided with Endo GIA linear 45 mm blue load stapler. [PICK ONE] A window was made at the base of the cecum, and it was transected with the Endo GIA linear 45 mm blue load stapler. The mesoappendix was divided with the harmonic scalpel. The staple line was intact and hemostatic. The appendix was placed in the bag and removed through the umbilical incision. The right lower quadrant was inspected there is again staple line looked good and there was no abscess or fluid collections. The umbilical fascia was closed with a size 0 Vicryl suture in a figure-of-eight fashion using a Carter Thomason device. The skin was closed throughout with 4-0 Monocryl and dressed with Dermabond. Final counts were correct. The patient was liberated from anesthesia and transported PACU in stable condition. Dr. []was present for the entire case.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, all boney areas padded, and secured to the table with straps. [abx] was given prior to the start of the procedure. The abdomen was prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. The abdomen was accessed via optical trocar in the left upper quadrant and insufflated to 15 mmHg. The area was inspected and there was no bleeding or visceral injury. A 12 mm subxiphoid, 5 mm supraumbilical, 5 mm right upper quadrant and 5 mm right lateral trocars were placed under direct vision without visceral injury in order to triangulate the gallbladder. The gallbladder was visualized and noted to be [appearance]. The gallbladder was retreated towards the patient’s right shoulder. [Adhesions]. The hepatocystic triangle was dissected with blunt technique and hook cautery until we achieved the critical view of safety noting two structures entering the gallbladder, the hepatocystic triangle clear of fatty and fibrous tissue and the lower one third of the cystic plate dissected. The cystic duct and artery were clipped with metal 5 mm clips in triplicate and transected with scissors. The gallbladder was separated from the cystic plate with hook cautery. It was placed in a bag. The clips were noted to be in place. The liver bed was noted to be hemostatic. The gallbladder was removed through the subxiphoid incision. This fascia was closed with size 0 Vicryl in a figure-of-eight fashion using the Carter Thomason device under direct vision. A total of [volume] cc of local anesthetic was injected to this fascial closure as well as the remaining incisions. The abdomen was desufflated. The skin incisions were closed with 4-0 Monocryl and dressed with derma bond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. Dr. [surgeon] was present throughout the entire procedure.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. A safety check was performed before induction of anesthetic and all were in agreement of patient and procedure and side. General anesthesia was induced the patient was intubated with a double-lumen ET tube. Bronchoscopy confirmed appropriate position of the tube and did not show any evidence of disease in the [] bronchi. The patient was placed in the [right/left] lateral decubitus secured with straps, [beanbag/anterior and posterior pads] and all bony prominences padded. Bronchoscopy was again performed confirming appropriate location of the double lumen ET tube. The [left/right] chest was prepped including the marker placed by the interventional radiologists, allowed appropriate time to dry and draped in normal sterile fashion. Timeout was done confirming patient, procedure, equipment, imaging, allergies and all were in agreement. The anesthesia team began single lung ventilation. The first incision was made along the mid axillary line approximately [number] rib space. This was carried down through the muscle layer and the pleural cavity was entered bluntly. A second port was placed along the anteriorly at the level of the [rib number] rib space under direct visulaization. Upon entering the pleural cavity it was noted that [findings]. CT guided marker string was visible in the [lobe]. The [lobe] at the location of the CT-guided marker was grasped and retracted and compression clamp was placed. Next the wedge resection was performed using sequential endogia staple loads. The specimen was divided from the remaining lung and the staple line and was noted to be hemostatic. The specimen was removed in a bag. The [nodule/marker/both nodule and marker] were palpated. Attention was turned to the inferior pulmonary ligament. This was released with electrocautery to the level of the inferior pulmonary vein. Level 9 lymph nodes were sampled and sent for permanent pathology. [other nodal station dictation] Posterior rib blocks were performed with Ropivacaine. Attention was turned to the port sites. Hemostasis was achieved with electrocautery. A [size] French chest tube was placed through the mid axillary line port and positioned superior to the lung to the apex of the thorax. The lung was inflated completely under direct visualization. The anesthesiologist did not note any air leak. The chest tube was connected to the atrium and to suction. A 2-0 Vicryl u-stitch was placed around the chest tube at the muscle layer. The chest tube was secured to the skin with 0 Ethibond. The anterior port was closed at the muscular layer with 2-0 Vicryl figure-of-eight stitch and at the deep dermal layer with buried interrupted 2-0 Vicryl. The skin was closed with running 4-0 Monocryl and Dermabond. Chest tube dressing was applied. All counts were noted to be correct. The patient was liberated from anesthesia uneventfully and transported the PACU in stable condition. Postoperative PACU chest x-ray with was ordered.

Sacral Ulcer Debridement Risks, benefits, alternatives discussed with the patient's HCP and informed consent was obtained. The patient was placed on the OR bed in supine position. General anesthesia was induced, and the patient was intubated without issue. The patient was positioned in the right lateral decubitus position. This was secured with a beanbag and all bony prominences padded. Straps were placed to secure the patient. Superficial wound cultures were taken. The wound was prepped with iodine and draped in a sterile fashion. Necrotic tissue was sharply debrided to the areas of healthy tissue around the wound using electrocautery. The deep tissue was debrided and there was no exposed bone. Debrided tissue was sent for culture and pathology. Hemostasis was achieved with topical lidocaine with epinephrine 10 cc and electrocautery. Wound measured [] ACell was placed throughout the entire wound bed covered with Xeroform and then sprayed with an additional local anesthetic and allowed to dry. Next bacitracin was placed and saturated with Xeroform. Dry Kerlix placed over this. ABD over this and secured with tape and finally Ioban was placed on top. The patient was replaced in the supine position liberated from anesthesia uneventfully and transferred to the PACU in stable condition.

Risks and benefits of bedside debridement were discussed with the HCP and witness informed consent was obtained. The patient was placed on their side and prepped with iodine and draped in the normal sterile fashion. Necrotic tissue was debrided sharply with a scalpel and scissors. The wound measured []. And there was [bone?]. Hemostasis was achieved with pressure. The wound was dressed with wet-to-dry Kirlex, ABD and secured with paper tape. The patient tolerated the procedure well and wound care instructions entered into the chart.

Bucket Abd x5 4x4 gauze x 1box ?Laceration repair kit 10 cc syringe x1 Blunt needle x1 25g injection needle x1 chucks pad x1 bottle normal saline x1 sterile gloves x2 paper tape roll x1 Kirlex roll x3

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. [A foley was placed]. [abx] was given prior to the start of the procedure. The patient was secured to the table and all boney areas padded. The abdomen was prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. The abdomen was accessed via optical trocar in the left upper quadrant and insufflated. The area was inspected and there was no bleeding or visceral injury. 11 mm supra umbilical, 5 mm right lateral, 5 mm right upper quadrant trocars were placed under direct visualization. The gallbladder was visualized and noted to be [appearance]. The gallbladder was retreated towards the patient’s right shoulder. Adheared stomach and fat were bluntly pushed away from the gallbladder. The hepatocystic triangle was dissected with blunt technique and hook cautery. The cystic duct and after were identified and skelatonized. The lower 1/3 of the gallbladder was dissected from the liver bed and the CVOS was achieved. The cystic duct and arteries were clipped in triplicate and transected with scissors. The gallbladder was separated from the cystic plate with hook cautery. It was placed in a bag. The clips were noted to be in place. The liver bed was noted to be hemostatic. The gallbladder was removed through the umbilical incision. The umbilical fascia was closed with 2-0 Vicryl and the Carter-Thomason device. An additional interrupted 2-0 Vircyl simple stitch was used. The abdomen was desufflated. The skin incisions were closed with 4-0 Monocryl and dressed with derma bond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. The attending surgeon was present throughout the entire procedure.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. [A foley was placed]. [abx] was given prior to the start of the procedure. The patient was secured to the table and all boney areas padded. The abdomen was prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. The abdomen was accessed via optical trocar in the left upper quadrant and insufflated. The area was inspected and there was no bleeding or visceral injury. A 12 mm infraumbilical trocar was placed and a 5 mm left lower quadrant trocar under direct visualization. The patient was placed in Trendenlenurg. The appendix was visualized in [area] and noted to be [perforated?]. The cecum was noted to be [appearance]. The appendix was grasped and retracted upwards. The mesoappendix was transected to the base using the Harmonic scalpel. The appendix was separated at its base using an EndoGia [color] staple load. The staple line was noted to be intact and hemostatic. The appendix was placed in a bag. The area was gently irrigated. The appendix was removed through the umbilical incision. The abdomen was desufflated and the umbilical fascia closed with 2-0 Vircyl using the Carter-Thomason device. The skin of all three incisions were closed with 4-0 Monocryl and dressed with Dermabond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. The attending surgeon was present throughout the entire procedure.

Informed consent was obtained. Preoperative antibiotics were provided. The patient was brought into the operating room and positioned supine upon the operating table. General anesthesia was induced, and the patient was intubated without complications. The left arm was tucked. The patient's abdomen was prepped with chlorhexidine and draped in standard sterile fashion. A timeout was performed, correctly identifying patient, procedure, site and side of surgery. All were in agreement. Access to the peritoneal cavity was gained safely through an incision in the left upper quadrant using the Optiview technique. The abdomen was examined which demonstrated no injury to the bowel. Pneumoperitoneum was achieved. A 12 cm port was placed in the left lower quadrant under direct visualization. A 5 mm suprapubic port was also placed. We then placed the patient in Trendelenburg with right side up. The appendix was located in [ ] and noted to be [ ]. A window was created with blunt dissection between the appendix and mesoappendix. The base of the appendix was transected with an Ethicon 45mm blue load Echelon Flex powered laparoscopic stapler. The mesoappendix was dissected using a Harmonic scalpel. The abdomen was examined thoroughly was deemed hemostatic. The 12mm port was extended to accommodate the large appendix. The appendix was removed in an EndoCatch bag. The abdomen was desufflated. A fascial closure was performed at the LLQ port site using an 0-Vicryl running stitch. Skin for all three incisions was approximated using 4-0 Monocryl and dressed with Dermabond. Instrument and sponge counts were correct at the end of the procedure. The patient was extubated in the OR and transferred to the PACU in stable condition. The attending surgeon was present and scrubbed during the entire procedure.

A timeout was done and all were in agreement.

The abdomen was prepped and draped in the normal sterile fashion. Upper endoscopy was performed which showed normal-appearing esophagus and stomach. External compression over the proposed PEG tube site showed 1-1 displacement of tissue. Finding needle was used and quickly entered the stomach in under 10 mm depth from the skin. It was deemed safe to proceed with PEG tube placement. A pull style 20 Fr PEG tube was utilized. Percutaneously a wire was passed and snared by the scope and was retracted out of the mouth. The pull style PEG tube was secured to this wire and retracted down the mouth into the stomach and out of the abdominal wall. Bumper was secured at 3 cm. Endoscopy was again performed to confirm good position of the PEG tube. The stomach was vented. The endoscope was removed. The patient tolerated the procedure well. The PEG tube was placed to gravity.

The patient was met in the surgical ICU, patient, consent, site and procedure to be performed confirmed. The patient was transported to the operating room and placed on the table in supine position. General anesthesia was induced and was already intubated. The patient was secured to the table with straps and all boney areas padded. A timeout was done and all were in agreement.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, all boney areas padded, and secured to the table with straps. [abx] was given prior to the start of the procedure. The abdomen was prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. The abdomen was accessed via supraumbilical cutdown and placement of 12 mm Hassan trocar. The abdomen was insufflated to 15 mmHg. The area was inspected and there was no bleeding or visceral injury. Three additional 5 mm ports were placed to triangulate the gallbladder. The gallbladder was visualized and noted to be [appearance]. It was retreated towards the patient’s right shoulder. [Adhesions]. The hepatocystic triangle was dissected with blunt technique and hook cautery until we achieved the critical view of safety noting two structures entering the gallbladder, the hepatocystic triangle clear of fatty and fibrous tissue and the lower one third of the cystic plate dissected. The cystic duct and artery were clipped with 5 mm Hemolock clips, three on the duct and two on the artery and transected with scissors. The gallbladder was separated from the cystic plate with hook cautery. It was placed in a bag. The clips were noted to be in place. The liver bed was noted to be hemostatic. The gallbladder was removed through the supraumbilical incision. This fascia was closed with size 0 Vicryl in a figure-of-eight fashion. A total of [volume] cc of local anesthetic was injected to this fascial closure as well as the remaining incisions. The abdomen was desufflated. The skin incisions were closed with 4-0 Monocryl and dressed with derma bond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. Dr. [surgeon] was present throughout the entire procedure.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, all boney areas padded, and secured to the table with straps. [abx] was given prior to the start of the procedure. The abdomen was prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. The abdomen was accessed via optical trocar in the left upper quadrant and insufflated to 15 mmHg. The area was inspected and there was no bleeding or visceral injury. Three additional 5 mm trocars were placed to triangulate the gallbladder as well as upsizing the original 5 mm trocar to 12mm all under direct vision without visceral injury. The gallbladder was visualized and noted to be [appearance]. The gallbladder was retreated towards the patient’s right shoulder. [Adhesions]. The hepatocystic triangle was dissected with blunt technique and hook cautery until we achieved the critical view of safety noting two structures entering the gallbladder, the hepatocystic triangle clear of fatty and fibrous tissue and the lower one third of the cystic plate dissected. The cystic duct was clipped with 5 mm hemolock clips in triplicate and transected with scissors. The gallbladder was separated from the cystic plate with hook cautery. The cystic artery was divided with hook cautery high on the gallbladder. It was placed in a bag. The clips were noted to be in place. The liver bed was noted to be hemostatic. The gallbladder was removed through the left upper quadrant incision. This fascia was closed with size 0 Vicryl using the Carter Thomason device under direct vision. A total of [volume] cc of local anesthetic was injected to this fascial closure as well as the remaining incisions. The abdomen was desufflated. The skin incisions were closed with 4-0 Monocryl and dressed with derma bond. The patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. [Dr. surgeon] was present throughout the entire procedure.

The patient was met in the surgical ICU, patient, consent, site and procedure to be performed confirmed. The patient was transported to the operating room and placed on the table in supine position. General anesthesia was induced and was already intubated. The patient was secured to the table with straps and all boney areas padded. A shoulder roll was placed. A timeout was done and all were in agreement. The neck was prepped with Betadine and draped in normal sterile fashion. A curvilinear incision over the expected location of the 1st and 2nd tracheal ring was made. The incision was carried down through the platysma. The strap muscles were identified and retracted laterally and preserved. The thyroid isthmus was retracted superiorly and preserved. The trachea was identified. A tracheal hook was used to lift the trachea and expose the 2-3rd tracheal ring. The anesthesia team deflated the balloon, reduced the Fi02. An tracheotomy was created with 15 blade and dilated with tracheal dilator. 2-0 Prolene stay sutures were placed in the superior and inferior aspect of the tracheotomy. The ET tube was retracted just above the level of the tracheotomy. A lubricated 7.5 cuffed Portex tracheostomy tube was placed. It was connected to the anesthesia circuit and there was return of end-tidal CO2. The tracheostomy wings were secured to the skin with 2-0 nylon. The stay sutures were secured to the chest and neck with Steri-Strips. All counts were correct.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. General anesthesia was induced and patient was intubated without issue. The patient was secured to the table with straps and all boney areas padded. The abdomen was prepped and draped in normal sterile fashion with addition of Ioban. Timeout was done and all were in agreement. The abdomen was entered in the right upper quadrant with Optiview trocar. The abdomen insufflated. There is noted to be no injury upon entry. Additional 5 mm ports were placed in the left upper quadrant right lower quadrant and left lower quadrant under direct vision. There was noted to be _. This was reduced with the help of the LigaSure. The defect was noted to be _ cm. A _ cm circular IPOM Parietene mesh was used. Four 0 PDS sutures were placed near the edge of the mesh in the cardinal directions. The mesh was introduced into the abdomen. The sutures were retrieved outside the abdomen percutaneously via 4 stab incisions around the umbilicus. The mesh was retracted up against the abdominal wall and these sutures were tied. The mesh was then secured with many SureStrap staples. The area was noted to be hemostatic. The abdomen desufflated and all ports were removed. All skin incisions were closed with 4-0 Monocryl and dressed with Dermabond. The patient was liberated from anesthesia and transferred to PACU in stable condition.

General Surgery Postoperative Instructions The following instructions will guide you through your post-operative care. If you have any questions, please do not hesitate to call the office or reach the covering physician via the answering service Wound Care: Your incisions are closed with absorbable suture. Glue is applied over the incision that will fall off on its own. Hygeine: Avoid scrubbing your surgical sites or immersing them (baths/pools etc) for the next few weeks. Simply let soapy water run over the area, rinse well and pat dry. Okay to shower starting tomorrow. Activity: You will gradually build up your endurance with normal day-to day activities around the home. However, avoid excessive straining (lifting >10 lbs), cadio exercise or deep stretching activities like yoga. You are safe to drive when you no longer need narcotic pain meds Medications and Pain Control: You may be sent home with pain medication to help alleviate pain after surgery.  These medications should only be taken if needed and as prescribed. Pain is usually the most severe for the first 24-48 hours after surgery and should improve over the next 1-2 weeks. Most of your surgical site pain will be controlled with over-the-counter Tylenol or Ibuprofen (Advil, Motrin). Alternate Tylenol and Ibuprofen every 3 hours for the first 1-2 days. Narcotic medications should be reserved for severe breakthrough pain and should always be taken with a stool softener to avoid constipation. Prescriptions are already be sent to your pharmacy. Only restart blood-thinning medications as discussed with your doctors. Diet: After anesthesia and some surgeries it may take several days for your appetite to fully return and before you can finish a regular portion size, but you may resume a normal healthy diet as tolerated with any restrictions discussed with your doctor. Avoid carbonated beverages which cause bloating pain and hydrate with plenty of water as your body recovers. If you had your gallbladder removed, you may better tolerate a low fat diet for 1-2 weeks and can expect some loose stools which typically resolve after a week. If you were treated for diverticulitis, you will be advised to continue a low fiber diet. Follow Up Instructions: Call the office as soon as possible to schedule a follow-up appointment in 2-3 weeks. You will be provided with work notes/disability forms If at any point in time you are unable to speak quickly with a physician and experience severe pain not alleviated with medication, high fevers (>102.5F), excessive bleeding, chest pain, difficulty breathing, or dizziness, call 9-1-1 or go to the emergency room for further evaluation We hope you had a good experience! Once again, do not hesitate to call the office if you have any questions or concerns and we will be more than happy to help out as you recover from surgery.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position. General anesthesia was induced and patient was intubated without issue. The patient was secured to the table with straps and all boney areas padded. The left inguinal area was prepped and draped in normal sterile fashion with Ioban. A timeout was done and all were in agreement. Incision was made over the medial aspect just above the inguinal ligament ligament. Incision was carried down through Scarpa's fascia external bleak was identified. This was opened along its fibers sharply with Metzenbaum along the length of the inguinal canal. The ilioinguinal nerve was identified and protected the cord was gently dissected away from the external oblique fascia and it was encircled with a Penrose drain. No direct hernia was noted. The cord was opened at the level of the cremasterics along their direction. The vas deferens and pampiniform plexus were identified and protected. A large indirect hernia was noted without any contents in the sac. This was gently and meticulously freed from the cord. It was simply reduced into the internal ring and the internal ring was closed slightly with interrupted 2-0 Vicryl in order to prevent the sac from coming back out. Polypropylene mesh was fashioned and was secured to the periosteum of the pubic tubercle with a single interrupted 0 PDS stitch. It was then secured to the conjoined tendon and internal oblique on the superior aspect of the floor and then to the shelving edge of the inguinal ligament on the inferior aspect all with interrupted 0 PDS. The internal ring was recreated with the tails of the mesh secured with 0 PDS on either side of the ring. It was not too tight. Hemostasis was achieved with electrocautery. External oblique was closed with running 2-0 Vicryl. Local field block was done with 1% lidocaine without epi. Scarpa's fascia was closed with interrupted Vicryl. Deep dermal was closed with interrupted Vicryl. It was closed with 4-0 Vicryl. The wound was dressed with Dermabond. The patient was awakened from anesthesia next day without issue and transported to PACU in stable condition.

Patient was met in the preoperative holding area all questions were answered patient was marked appropriately, consent was confirmed. Patient was transported to the operating room placed in the table supine secured with straps bony areas padded. Monitored anesthesia care was administered. The [side] chest was prepped and draped normal sterile fashion. Timeout was done all were in agreement. The subclavian was accessed with introducer needle return of dark nonpulsatile blood. J-wire was advanced. C arm x-ray showed the wire traversing into the IVC. Skin nick was made dilator sheath was placed and peeled while the tubing was placed. Next an incision was made just inferior to this and a pocket was made over the level of the pectoralis muscle fascia. A tunnel dilator was used to tunnel the tubing to this pocket. Next final confirmation of depth was done using fluoroscopic guidance terminating the tubing at the right atrial junction. The port was accessed with a Huber needle and easily return blood and was flushed. Final flush was done with 3 cc heparinized saline. The tubing was attached to the reservoir port and was secured to the pectoralis fascia using two interrupted 2-0 Vicryl. The incision was closed in layers with 3-0 Vicryl, 4-0 Monocryl, Dermabond and the percutaneous access site in the same way. Patient was liberated from monitored anesthesia care and transported to the ASU in stable condition. Postop x-ray was ordered. Dr. [attending] was present and scrubbed for the entire procedure

Kaleida Discharge Instructions DANGER SIGNALS/SIGNS TO CALL ABOUT (716-833-7112): If there is redness, swelling or increased pain at the incision site. If there is yellowish-white fluid(pus) coming from the incision/wound. If you notice a bad smell coming from the incision/wound. If the wound or sutures break open. If you experience dizzy spells or faintness. If you develop nausea, vominting, constipation or diarrhea. If you develop a fever greater than 101.5 or chills. If you develop a rash. If you experience a reaction or side effect from new medications. If you develop severe abdominal pain. If you develop leg pain. ACTIVITY: Your primary form of exercise will be walking. You can bend, twist, turn, go up/down stairs, pick things off the floor. No lifting objects > 10 pounds for 4-6 weeks Driving: NO DRIVING WHILE TAKING NARCOTIC PAIN MEDICATION Most patients can drive in 2-3 days and no longer taking narcotic pain medications Travel: Short distances as tolerated. HYGIENE: You can shower in 24 hours after surgery Water and soap can was over your incisions; no scrubbing No baths, hot tubs, swimming pools for 4 weeks DIET: As tolerated. It is recommended to avoid heavy/greasy meals for the first 1-2 days. A decrease in appetite after surgery is normal for several days. Do not feel like you need to finish your plate/meal WOUND CARE: Ok to shower in 24 hours after surgery. The purple skin glue will fall off in 7-10 days. If it still is on 2 weeks after surgery you can remove it in the shower. PAIN CONTROL: You can take Tylenol (650 mg) every 6 hours and Ibuprofen (400 mg) every 6 hours. We recommend alternating the medications and taking something every 3 hours. For example: 6 am take 650 mg tylenol 9 am take 400 mg Ibuprofen 12 pm take 650 mg Tylenol again 3 pm take 400 mg Ibuprofen again A prescription for oxycodone 5 mg will be sent to your pharmacy and this can be taken every 6 hours as needed for pain Take Miralax as needed for constipation FOLLOW UP:

The patient was brought to the operating room and placed in the supine position. General anesthesia was initiated without incident. Preoperative antibiotics were administered. The umbilicus was prepped and draped in standard sterile fashion. A timeout was performed by which the patient was identified using 2 patient identifiers, and the site and proposed procedure were confirmed. All team members agreed. A 6cm curvilinear supraumbilical incision was made using a #15 blade and carried down into the subcutaneous tissues using electrocautery and assuring hemostasis along the way. Defect in the fascia was noted deep to our incision. A hernia sac was identified more caudal to the initial fascial defect with a second defect in the fascia seen. We dissected circumferentially around the hernia sac away from the fascia using a mix of electrocautery and blunt finger dissection. The sac was ligated and handed off for specimen. The defect was estimated at _ cm in length. A _ mesh was placed at the _ level. The fascia was closed with _. The umbilicus was reapproximated to the underlying fascia using a 3-0 Vicryl sutures. The surgical site was instilled with 15ml of a 1:1 mixture of 0.5% Marcaine and 1% lidocaine with epinephrine. The remainder of the incision was closed in layers using 3-0 Vicryl interrupted sutures in the deep dermal layer. We then place a 4-0 Monocryl running subcuticular suture. The incision was covered with Dermabond. A sterile dressing with a cotton ball in the umbilicus was placed after the Dermabond had dried. The patient was liberated from anesthesia and brought to the PACU in stable condition. The sponge, instrument and needle counts at the end procedure were all correct. The attending was present and active for the entirety of the procedure.

The patient was brought to the operating room and placed in the supine position. General anesthesia was induced and airway was secured with GET. The left groin was prepped and draped in standard sterile fashion. Preoperative antibiotics were administered. A timeout was performed by which the patient was identified using 2 patient identifiers, and the site and proposed procedure were confirmed. All team members were in agreement. A 5cm oblique incision was made 1 finger's breadth above the inguinal ligament between the ASIS and pubic tubercle using the 10 blade. Using electrocautery this was carried down to the external oblique aponeurosis as hemostasis was assured along the way. The external oblique aponeurosis was identified, cleared of overlying tissues, and incised. The incision was carried medially to the external ring and laterally to reveal the underlying cord. The ilioinguinal nerve was identified and transected with Metzenbaums scissors. The spermatic cord structures were bluntly dissected off of the posterior aspect of the external oblique aponeurosis using finger dissection. The spermatic cord and hernia sac were then finger dissected off of the floor of the inguinal canal at the level of the pubic tubercle. The hernia sac was then separated from the spermatic cord. Cord lipoma was identified and reduced into the peritoneal cavity. The internal ring was approximated with a figure of eight stitch using a 2-0 vicryl We then turned our attention to our hernia repair. The Prolene keyhole mesh was secured to the pubic tubercle with prolene. The inferior border was sutured to the shelving edge of inguinal ligament with running prolene. The superior border was sutured to the transversalis fascia with interrupted prolene sutures. Care was taken not to entrap any nerves. The hernia defect was completely covered by the mesh overlapping onto normal healthy tissue and we were satisfied with the extent of our repair. The internal ring was re-created by suturing the tails of the mesh together, with care taken to avoid impinging on the cord structures. A small finger was easily able to pass in the reconstructed ring. The surgical incision was then irrigated and hemostasis was assured. The cord was verified to be intact and in a neutral position. The mesh repair was tension free and flat. The external oblique fascia was closed in a running fashion with 3-0 Vicryl. The remainder of the incision was closed in layers using 3-0 Vicryl running sutures in Scarpa's fascia and interrupted deep dermal layer. 10 cc local anesthetic was injected. Skin was then closed with a 4-0 Monocryl running subcuticular suture. The incision was covered with Dermabond. The testicles were palpated and were mobile and normal to inspection. At the completion of the procedure, the patient was transferred to the cart and brought to the PACU in stable condition. The sponge, instrument and needle counts at the end procedure were correct x2. The attending was present and active for the entirety of the procedure.

Date of surgery: Preoperative diagnosis: Postoperative diagnosis: Procedure performed: Attending surgeon: Asst. surgeon: Estimated blood loss: Complications: Findings: Specimens: Indications: Discussion of procedure:

The patient was brought to the operating room and placed in the supine position. General anesthesia was initiated without incident. The right groin was prepped and draped in standard sterile fashion. Preoperative antibiotics were administered. A timeout was performed by which the patient was identified using 2 patient identifiers, and the site and proposed procedure were confirmed. All team members were in agreement. An 6cm oblique incision was made 1 finger's breadth above the inguinal ligament between the ASIS and pubic tubercle. Using electrocautery this was carried down to the external oblique aponeurosis as hemostasis was assured along the way. The external oblique aponeurosis was identified, cleared of overlying tissues, and incised with Metzenbaum scissors. The incision was carried medially to the external ring and laterally to reveal the underlying cord. The spermatic cord structures were bluntly dissected off of the posterior aspect of the external oblique aponeurosis using finger dissection. The spermatic cord was then finger dissected off of the floor of the inguinal canal at the level of the pubic tubercle and encircled with a Penrose drain. There was noted to be ***. The Prolene 6.1 x 13.7cm keyhole mesh was secured to the pubic tubercle with 0 Prolene. The inferior border was sutured to the shelving edge of inguinal ligament with a running 0 Vicryl suture. With care taken to ensure that the mesh sat flat on the floor of the inguinal canal, the superior border was sutured to the transversalis fascia with interrupted 0 Vicryl sutures. Care was taken not to entrap any nerves. The hernia defect was completely covered by the mesh overlapping onto normal healthy tissue and we were satisfied with the extent of our repair. The internal ring was re-created by suturing the tails of the mesh together, with care taken to avoid impinging on the cord structures. A small finger was easily able to pass in the reconstructed ring. The surgical incision was then irrigated and hemostasis was assured. The cord was verified to be intact and in a neutral position. The mesh repair was tension free and flat. The external oblique fascia was closed in a running fashion with 2-0 Vicryl. The remainder of the incision was closed in layers using 3-0 Vicryl running sutures in Scarpa's fascia and interrupted deep dermal layer. 10 cc local anesthetic was injected. Skin was then closed with a 4-0 Monocryl running subcuticular suture. The incision was covered with Dermabond. The testicles were palpated and were mobile and normal to inspection. The patient was liberated from anesthesia and brought to the PACU in stable condition. The sponge, instrument and needle counts at the end procedure were correct x2. The attending present and active for the entirety of the procedure.

Activity: No lifting pushing or pulling over 10 lbs for 6 weeks. Encourage out of bed and walking Pain control. Apply icepacks. Alternate Tylenol and ibuprofen every four hours. Take oxycodone as necessary. Take stool softener for constipation. Wound care: Incision covered with glue that will fall off on its own. Hygiene: Okay to shower after 2 days. Do not submerge in water for 6 weeks.

Patient is scheduled for [procedure] on [date]. -CBC w/ diff, CMP, Type and screen, INR/PTT, morning of surgery -preoperative EKG, CXR if not yet done this admission -NPO with IVF midnight before surgery

The patient was met in the preoperative holding area all questions were answered and consent was confirmed. The patient was transported to the operating room placed on the OR table, bony areas padded, sequential compression devices applied to the bilateral lower legs, secured with straps and beanbag. General anesthesia was induced and the patient was intubated without issue. The abdomen was prepped and draped in normal sterile fashion. Preoperative Ancef was given prior to incision. A timeout was done and all were in agreement. The abdomen was insufflated via Veress needle in the [location] to 8 mmHg. Left upper quadrant optical trocar entry was then done with an 8 mm robotic port. There was no visceral injury noted on this entry or the Veress needle. The remainder of the two 8 mm robotic ports were placed to triangulate the gallbladder. A right lateral 5 mm port was placed for retraction. The robot was docked, and we took place on the console. The gallbladder was inspected and there were noted to be [adhesions]. The gallbladder was noted to be [inflamed, non-inflamed], and was drained with a laparoscopic decompressive needle. I dissected the triangle of Calot, isolating the cystic duct and cystic artery, dissecting the lower one third of the cystic plate off of the liver bed. The hepatocystic triangle was fully cleared of fibrofatty tissue and the critical view of safety was confirmed prior to any clipping or cutting. A timeout was done noting only two structures going through the hepatocystic triangle towards the gallbladder, the triangle free of fibrofatty tissue and the lower one third of the gallbladder dissected off the fossa confirming the critical view of safety. The cystic duct was clipped in triplicate, and a single clip was placed on the artery. The duct was transected with cut electrocautery on the hook. The artery was transected with coagulation electrocautery. The gallbladder was freed from the fossa with hook cautery. It was extracted in a bag. Hemostasis was achieved and confirmed to the liver bed with electrocautery. The camera port was placed to the right of midline, and the fascia did not need to be dilated to extract the gallbladder therefore there was no indication to close the fascia. All skin incisions were closed with running 4-0 Vicryl and Steri-Strips. [volume] cc of local anesthetic was injected throughout all incisions as a local field block. Final counts were correct. The patient was liberated from anesthesia extubated and transported to the PACU in stable condition. Dr. [attending] was present for the entire case.

1. Laparoscopic peritoneal dialysis catheter placement (CPT 49324) 2. Omentopexy (CPT 49326) The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, boney areas padded, sequential compression devices applied to the bilateral lower extremities and secured with straps. General anesthesia was induced, and patient was intubated without issue. Preoperative Ancef was given. The abdomen was prepped and draped in the normal sterile fashion. Timeout was done and all were in agreement. I accessed the abdomen was accessed with 5 mm Optical trocar entry in the right upper quadrant and the abdomen insufflated to 15 mmHg. There was no injury on entry. An additional 5 mm and 8 mm ports were placed under direct vision the right hemi abdomen without injury. Using a 5 mm trocar through a periumbilical incision a tract was created in the preperitoneal space towards the pubis and entered into the peritoneal cavity. The wire was passed, the dilator next and sheath and then the peritoneal dialysis catheter was fed into the pelvis under vision. The proximal cuff was placed below the level of the fascia, and the distal end of the tube was tunneled out through a left upper quadrant incision with the distal cuff in the subcutaneous tissue. We tested the catheter by instilling 1L of normal saline and ensuring it was adequately drained. A heparin flush was instilled. Next, I did an omentopexy to the anterior abdominal wall with size 2-0 Stratafix Monocryl spiral suture. The operative field was noted to be hemostatic. I desufflated the abdomen. The skin incisions were closed with size 4-0 Monocryl in a running fashion and dressed with Dermabond. The exit site of the catheter was dressed with bacitracin, an antimicrobial ring, abdominal pads and secured with occlusive Tegaderm. The patient was liberated from anesthesia an extubated without issue and transported to the PACU in stable condition. Final counts were correct. Dr. [attending] was present or available for all critical aspects of the case.

PREOPERATIVE AND URETERAL STENTS The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, SCDs were applied. General anesthesia was induced, and patient was intubated without issue. The patient was secured to the table with straps and all boney areas padded and placed in the [position] for placement of ureteral stents. Dr. [ ] performed the stent placement, see procedure note for full details. After this the patient was returned to the [position] and the abdomen prepped and draped in the normal sterile fashion. A timeout was done and all were in agreement. ABDOMINAL ACCESS, PORT PLACEMENT AND SURVEY Access to the abdomen was achieved with [5 vs 8] mm optical trocar entry. The abdomen was insufflated to 15 mmHg and there was noted to be no injury made on entrance. The abdomen was surveyed and found [findings]. Additional trocars were placed triangulating the RLQ and pelvis, under direct vision without noted injury. 12 mm RLQ 8 mm right mid abdomen 8 mm supraumbilical [**] The original 5 mm entry trocar was exchanged for an 8 mm robotic trocar [**] Lysis of adhesions were done for [ ] minutes. The colon was examined and was noted [ ]. COLON DISSECTION AND DISTAL TRANSECTION. The sigmoid colon mesentery was placed on tension to help identify the IMA pedicle. Adjacent to this the avascular retromesenteric space was entered and the mesentery was separated from the retroperitoneum, ensuring preservation of the neurovascular bundles. Next the sigmoid was dissected laterally from the pelvic brim to meet this plane. The colon was further mobilized by releasing the white line of Toldt and blunt separation from Gerota's fascia to the level of the [colon]. At the level of the proximal rectum the bowel was cleared of fat and mesentery, and it was transected with the linear robotic stapler with blue cartridge. PROXIMAL TRANSECTION AND ANASTMOSIS The robot was undocked and a Pfannenstiel incision was made and carried down to the peritoneal cavity, sparing the rectus muscles. An [wound protector] wound protector was placed. The proximal bowel was delivered and noted to have [findings], the proximal transection line was decided based off a lack of colonic thickening and diverticula. An automatic purse string device was used and the colon sharply resected. The anvil was placed and secured with this purse string and an additional 0 Vicryl tie. The bowel was returned to the abdomen; the cap placed on the wound protector and the abdomen reinsufflated and the robotic redocked. The proximal bowel was freed from remaining attachments, and it reached the rectal stump easily. The anus and rectum were sequentially dilated. The [mm] mm EEA [powered vs non-powered] stapler was passed, the spike opened and mated with the anvil and a circular [anastomosis type] was created. The anastomotic donuts were inspected and noted to be [findings]. Flexible sigmoidoscopy was done which showed intact anastomosis circumferentially and the leak test was negative. The abdomen was again inspected and noted to be hemostatic. Bilateral TAP blocks were done with [cc] cc of [local anesthetic]. The robot was undocked and abdomen desufflated. CLOSURE The peritoneum was closed with [suture] in a [fashion]. The facia of the Pfannenstiel incision waws closed with [suture] in a [type] fashion. The skin was closed throughout with 4-0 Monocryl. The port sites were dressed with Dermabond and the Pfannenstiel with Prevena. The final counts were correct. The stents were removed and noted to be intact. The foley had hematuria which is expected. The patient was liberated from anesthesia, extubated without issue and transported to PACU in stable condition. Dr. [ ] was present and participated for the entire case.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. Subcutaneous heparin was given in the preop area. The patient was transported to the operating room and placed on the table in supine position, SCDs applied, preoperative cefoxitin given. The patient was secured to the table with straps and all boney areas padded. General anesthesia was induced and patient was intubated without issue. A foley catheter was inserted. A small Kocher incision was made big enough to fit a single hand. Palpation of the peritoneal cavity did not reveal any obvious intraperotineal disease. The Kocher incision was widened and the Bookwalter retractor was used. We were met with adhesions from previous laparoscopic cholecystectomy that were lysed with electrosurgical devices for [ ] minutes. There was a thick adhesion and mass on the right mid abdominal wall that was biopsied and sent for frozen pathology that returned negative for malignancy. We next explored the retropancreatic head space, there was noted to be no anatomic vascular variants, and we dissected and removed two lymph nodes that were sent for permanent pathology. These lymph nodes were soft and not concerning for disease. We encountered venous bleeding from a branch separate from the portal vein that was controlled with a large clip. This area was packed with SurgiFoam. The falciform was divided and made hemostatic with 3-0 silk ties. Next we turned our attention to the hepatoduodenal ligament which was stripped of it's lymphatic tissue including excision of a lymph node overlying the left gastric artery. No concerning lymph nodes were encountered. Happy with our lymphadenectomy we proceeded with hepatic wedge resection. A dissection line 2 cm deep to the gallbladder fossa was outlined. A Pringle maneuver was performed and this area of liver was resected with the Harmonic scalpel. Brisk venous bleeding was controlled with figure of eight 3-0 Prolene stitches. The specimen was removed and sent for permanent pathology. The liver edge was made further hemostatic using spray Bovie cautery. The liver edge was inspected and there was noted to be no leakage of bile. The cystic duct margin from the original cholecystectomy was widely free of any disease so additional cystic duct resection was not indicated. SurgiFoam was packed into the resected liver bed. A 10 Fr JP drain was introduced through the right abdomen and placed in the gallbladder fossa. The fascia was closed with 0 PDS suture in a figure-of-eight fashion at the midline. Then the remainder of the incision was closed by first closing the posterior layer with 0 PDS in a running fashion followed by the anterior layer in the same fashion. The wound was further irrigated and the skin was closed with staples and dressed with a Prevena dressing. The patient tolerated the procedure well and remained stable. She was liberated from anesthesia and extubated without issue and transported to the surgical intensive care unit in stable condition.

Patient was met in the preoperative holding area all questions were answered patient was marked appropriately, consent was confirmed. Patient was transported to the operating room placed in the table supine secured with straps bony areas padded, SCDs applied. Preoperative Ancef was given. General anesthesia was induced and intubated without issue.. The chest was prepped and draped normal sterile fashion. Timeout was done all were in agreement. The subclavian was accessed with introducer needle return of nonpulsatile blood. J-wire was advanced. C arm x-ray showed the wire traversing into the IVC. The blood was somewhat bright so we connected the intraluminal needle to extension tubing and it was clear it was not high pressure or pulsatile. Skin nick was made dilator sheath was placed and peeled while the tubing was placed. Next an incision was made just inferior to this and a pocket was made over the level of the pectoralis muscle fascia. A tunnel dilator was used to tunnel the tubing to this pocket. Next final confirmation of depth was done using fluoroscopic guidance terminating the tubing at the right atrial junction. The port was accessed with a Huber needle and easily return blood and was flushed. Final flush was done with 2 cc heparinized saline. The tubing was attached to the reservoir port and was secured to the pectoralis fascia using a single interrupted 3-0 Vicryl. The incision was closed in layers with 3-0 Vicryl, 4-0 Monocryl, Dermabond and the percutaneous access site with 4-0 Monocryl and Dermabond. Patient was liberated from anesthesia, extubated and transported to the PACU in stable condition. Postop x-ray was ordered. The port implanted was: 9.6F BardPort (0602680) Dr. [ ] was present and scrubbed for the entire procedure

Patient was met in the preoperative holding area. Informed consent was confirmed. All questions answered. Patient was transported to the operating room and placed supine on the table. Bony areas are padded and the patient was secured with straps. Sequential compression device devices were applied to the calves. General anesthesia was induced without issue and the patient was intubated successfully. Preoperative antibiotics were given. The patient was prepped and draped in the normal sterile fashion. Timeout was done and all were in agreement. Access the abdomen was gained via open approach in the supraumbilical area and a 10 mm Hassan trocar was placed. The abdomen was insufflated to 15 mmHg and there was noted to be no injury to the bowel. Three additional 5 ports replaced triangle in the gallbladder under direct vision without visceral injury. The gallbladder is retracted towards the right shoulder. Dissection proceeded with hook cautery to free the lower one third of the gallbladder fossa and clear the hepatocycstic triangle of tissue and obtained the critical view of safety. The cystic artery was transected with hooky during this and noted to be hemostatic. The cystic duct was triple clipped on the stay side and transected sharply. The cystic artery was clipped and transected sharply. The gallbladder was removed from the fossa. [bile spillage?] The gallbladder fossa was gonna be hemostatic after this. The clips were noted to be in a good position. The gallbladder is placed in a bag and retrieved through the umbilical incision. The abdomen was completely dessuflated. The umbilical incision was close primarily with size zero Vicryl suture in a figure-of-eight fashion. [volume] cc local anesthetic was injected throughout. The skin was closed with size 4-0 Monocryl and dressed with Dermabond. Final counts were correct. The patient was liberated from anesthesia and transported to the PACU in stable condition. Dr. Brewer was present the entire case.

Patient was met in the preoperative holding area, consent was confirmed and all questions were answered. Patient was transported back to the operating room placed on the OR table in the supine position, bony areas padded, left arm tucked, sequential compression devices applied to the bilateral legs and secured with straps. General anesthesia was induced, and patient was intubated without issue. [Abx] was given prior to the procedure. The abdomen was prepped and draped in normal sterile fashion and a timeout was done and were all in agreement. The abdomen was accessed via supraumbilical cutdown and placement of 12mm trocar. The abdomen was insufflated to [8/15] mmHg there was no visceral injury upon entry. A 5 mm port was placed in the left lower quadrant area as well as a 5 mm left mid abdomen port under direct vision without visceral injury. The patient was positioned in Trendelenburg position with right side up. The abdomen was surveyed, the small bowel pushed aside, and the cecum and the right colon were gently moved medially revealing the appendix. It was noted to be [appearance]. [Accessory ports] [PICK ONE] The mesoappendix was divided with the harmonic scalpel to the base of the appendix. The appendix was divided with Endo GIA linear 45 mm blue load stapler. [PICK ONE] A window was made at the base of the cecum, and it was transected with the Endo GIA linear 45 mm blue load stapler. The mesoappendix was divided with the harmonic scalpel. The staple line was intact and hemostatic. The appendix was placed in the bag and removed through the umbilical incision. The right lower quadrant was inspected there is again staple line looked good and there was no abscess or fluid collections. The umbilical fascia was closed with a size 0 Vicryl suture in a figure-of-eight fashion. The skin was closed throughout with 4-0 Monocryl and dressed with Dermabond. Final counts were correct. The patient was liberated from anesthesia and transported PACU in stable condition. Dr. [] was present for the entire case.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room and placed on the table in supine position, boney areas padded, sequential compression devices applied to the bilateral lower extremities and secured with straps. General anesthesia was induced, and patient was intubated without issue. Preoperative Ancef was given. Timeout was done and all were in agreement. I accessed the peritoneal cavity with a Veress needle through the [umbilicus/LUQ] and insufflated the cavity to 8 mmHg. Then I used optical trocar technique to place an 8mm port in the left upper quadrant. There was no visceral injury with this or the Veress needle. Two additional 8 mm robotic ports were placed under direct vision without injury to triangulate the pelvis. I noted an [hernia]. The robot was docked, and we took our place on the console. On the [left/right] side I created a preperitoneal flap exposing the myopectineal orifice, exposing the pubis medially and the lateral abdominal wall laterally. I reduced the direct hernia which contained fat. There was a patent deep inguinal ring without hernia sac or contents. I made sure to free the inferior peritoneum enough to allow for flat mesh placement. The fascia of the direct hernia space as well as the internal ring were re-approximated with size 2-0 V-lock suture in a running fashion. A 9 x 11 cm ProGrip mesh was placed over the myopectineal orifice with wide overlap of the defect. The medial edge was over the pubis and the inferior edge laid flat. The peritoneal flap was closed with size 2-0 V-lock suture in a running fashion. The abdomen was desulfated, the robot undocked and the incisions closed with 4-0 Vicryl and 5-0 plain gut and dressed with Steri-strips. The final count was correct. The testicles were palpated in the scrotum. Dr. [attending] was present or available for the entire case.

The patient was met in the preoperative holding area, patient, consent, site and procedure to be performed confirmed. All questions answered. The patient was transported to the operating room. Sequential compression devices applied to the bilateral lower extremities. General anesthesia was induced, and the patient was intubated on the cart. The patient was transferred to the operating table in prone position, boney areas padded and secured with straps. The lower back and gluteal cleft were prepped and draped in the normal sterile fashion. Preoperative Ancef was given. A timeout was done and all were in agreement. An ellipse incision was made around the visible pits and carried down to the level of the fascia and this area was completely excised. The operative field was made hemostatic with cautery. The wound was closed in layers with 2-0 Vicryl, 3-0 Vicryl and 4-0 Monocryl and dressed with Dermabond. Final counts were correct. The patient was transferred back to the cart, liberated from anesthesia, extubated and transported to PACU in stable condition.