外科手術(shù)記錄翻譯模板 中譯英

Sino-Japanese Friendship Hospital, Ministry of Health

Surgical Records

Name XXX

(Page 1)

Medical Record No. 1346384

Name: SUN YAN MI        Gender: female        Age: 48 years old        Department: gastrointestinal surgery        Bed No.: 11

Date of Surgery: October 26, 2012

Preoperative Diagnosis: 1. gastric cancer   2. post-total hysterectomy                                Initial Time of Surgery: 14:15

Intraoperative Diagnosis: 1. gastric cancer   2. post-total hysterectomy                               Final Time of Surgery: 16:15

Name of Surgery: radical gastrectomy for gastric cancer (distal subtotal gastrectomy + Billroth I)           Total Time of Surgery: 2 hours

Surgical Incision: II

Surgeon: Wenyue Wang       Assistant I: Lei Zhou   Assistant II: Guochao Zhang   Assistant III: Jinyong Li

Anesthetic Method: general anesthesia 

Anesthesiologist: Chunxia Liu

Surgical Procedure: After the success of general anesthesia, the patient lay flat on the operating table with conventionally disinfected sterile towel. The abdominal median incision was about 20cm long. After entry into the abdomen layer by layer, there was not a condition known as ascites. And after exploration, liver, gallbladder, spleen, transverse colon, the root of the small bowel mesentery, parietal peritoneum and pelvis showed no metastasis. There was a visible hard palpable mass in the lesser curvature of the gastric antrum, with the dimensions of about 4*3cm, without invasion through the serosa layer. The gastrocolic ligament in the upper edge of transverse colon was cut, the anterior lobe of transverse mesocolon was seperated up to the lower edge of the pancreas, and then the pancreatic capsule was separated to the upper edge of pancreas. The root of the right gastroepiploic artery was dissociated, and the right gastroepiploic artery was disarticulated and ligated at the root of gastroduodenal artery branch. The lymph nodes of Group 6 and Group 11p were dissected. The small omentum was dissociated, and was cut at the lower edge of the liver. The hepatoduodenal ligament and the lymph nodes around the hepatic artery and along the superior mesenteric vein (Groups 8, 9, 12a, 14v) were desected. The right gastric artery was interrupted to clear peripheral lymph nodes (Group 5). About 2cm at the right side of the pylorus, purse-string forceps were applied to disarticulate the duodenum. The left gastric artery and vein were cut off to clear the lymph nodes of Group 7.  The distal stomach was dissociated along the gastric lesser curvature and the gastric greater curvature to clear the lymph nodes of Groups 1 and 3 from the lesser curvature and the lymph nodes of Groups 3 and 4. The en bloc resection of specimen was performed up to the gastric pre-resection line. The proximal stomach is about 5cm away from the tumor, and the distal stomach is about 5cm away from the tumor. The en bloc resection of specimen was performed. The anastomat was applied for gastroduodenal anastomosis. The closure device was applied for the closure of gastric incision. The gastroduodenal anastomosis was checked for patency without stenosis. The haemorrhage of abdominal cavity was completely controlled. 1g fluorouracil implant was put into the tumor bed. The 2 peritoneal drainage pipes were rotated by the side of anastomosis. After the surgical instruments were checked off, the abdomen was closed layer by layer. The surgical procedure was successful. During the surgery, about 80ml blood has flowed out, without blood transfusion, and the patient’s blood pressure was stable, with satisfactory anesthesia. The resected specimen was submitted for pathological examination. The patient safely returned to the ward after regaining consciousness. The surgery was completed.

Blood Loss: 80 ml

Blood Transfusion: 0 ml

Drainage and Specifications: 2

Intraoperative Pathologic Findings: The same as above

Specimen Whereabouts and Time: Department of Pathology

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