OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS:
History of Crohn
disease with nodularity and deformity of the ileocecal valve region now followed
with colonoscopy.
POSTOPERATIVE DIAGNOSES:
Severe deformity of
the ileocecal valve region with ileal stricture formation status post biopsy,
separate polypoidal process appearing within the caput cecum in the
periappendiceal region status post biopsy submitted in a separate
container.
TITLE OF OPERATION:
Colonoscopy with
biopsies.
PROCEDURE:
After the patient was placed in the
left lateral decubitus position, the doctor administered anesthesia until the
patient was sedated.
Once adequately sedated, the video pediatric colonoscope was
introduced into the patient's rectum and advanced into the cecum. Cecal
location was confirmed by characteristic architecture and transillumination in
the right lower quadrant. Within the caput cecum in the periappendiceal
region, a polypoidal process was noted. Biopsies were obtained. The
instrument was withdrawn to the ileocecal valve area, which had significant
stricture formation, scarring and nodularity and a separate set of biopsies were
obtained of this region. The instrument was withdrawn to the ascending and
transverse colons where it was noted to have diverticulosis. In the
rectum, no further pathology was seen. The instrument was withdrawn from
the patient's anus.
The patient tolerated the procedure well and returned to recovery
room in satisfactory condition.
Gastro Medical Transcription
Report