剖腹探查术手术记录

贵航集团302双阳医院
手术记录
1、患者平卧位于手术台上，麻醉成功后，依次消毒铺巾。

2、取右下腹麦氏切口，长约5CM依次切开皮肤及皮下各层，进腹后探查
可见：沿结肠袋找到回盲部，见回盲部包裹，回盲部有少量脓性分泌物，回盲部水肿，阑尾被炎性组织包裹，依次分开炎性组织，寻找到阑尾，见阑尾根部水肿，距阑尾根部约切断阑尾，7号丝线结扎。

3、阑尾根部因炎性浸润未做荷包缝合。

阑尾残端大网膜覆盖2针，查无
出血，清点手术器械纱布无误后，替硝唑冲洗腹腔，放置腹腔引流管1枚，关腹。

4、手术顺利，麻醉满意，病人安返病房，术毕。

记录者：***。

肝破裂剖腹探查术手术记录范文英文回答：The surgical procedure performed was an exploratory laparotomy for liver rupture. The patient was a 45-year-old male who presented to the emergency department with severe abdominal pain and signs of internal bleeding. Upon examination, it was determined that the patient had sustained a liver rupture, which required immediatesurgical intervention.The patient was placed under general anesthesia, and a midline incision was made in the abdomen to access the abdominal cavity. Upon entering the peritoneal cavity, a significant amount of blood was observed, indicating active bleeding. The liver was carefully inspected, and a large laceration on the right lobe was identified as the source of the bleeding.To control the bleeding, the surgeon applied pressurewith gauze pads and used electrocautery to achieve hemostasis. The laceration was then repaired with sutures, ensuring a tight closure to prevent further bleeding. In addition, a drain was placed near the liver to allow for drainage of any residual blood or fluid.During the procedure, the surgeon also inspected other organs in the abdominal cavity to rule out any additional injuries. No other injuries were identified, and the abdominal cavity was thoroughly irrigated to remove any remaining blood or debris.After completing the necessary repairs and ensuring hemostasis, the abdominal incision was closed in layers using sutures. The patient was then transferred to the post-anesthesia care unit for recovery.中文回答：进行的手术是肝破裂剖腹探查术。

手术记录
住院号:xx 科室:普外科住院号： xx 床位号：5
姓名:xx 性别:男年龄:45岁手术日期：2019年09月07日术前诊断：消化道穿孔拟施手术：剖腹探查术
术中诊断：回肠穿孔；弥漫性腹膜炎
术后诊断：回肠穿孔，弥漫性腹膜炎已施手术：剖腹探查术+肠梗阻
减压术+穿孔处肠壁切除术+回肠穿孔修补术
手术名称：剖腹探查术+肠梗阻减压术+穿孔部肠壁切除术+回肠穿孔修补术麻醉方式：全麻麻醉医师：xx
麻醉开始时间： 20时25分麻醉结束时间： 22时30分共计： 02时05分
手术开始时间： 20时25分手术结束时间： 22时30分共计： 02时05分
手术人员：主刀xx 助手xx
手术过程：探查见回肠距回盲部约1米处直径约3.5cm穿孔，其内粪便溢出，腹
腔内大量淡红色渗出液体,肝胆胰脾未见明显异常。

1．气插全麻，平卧位,常规消毒铺巾。

2．上腹部正中切口长15cm,上至剑突下,下至脐,逐层切开进腹。

探查腹腔，
如术中所见。

决定行剖腹探查术+肠梗阻减压术+穿孔部肠壁切除术+回肠穿孔修补术。

3．清洗穿孔口，用无菌套膜围绕穿孔处，主刀用双手轻柔挤压扩张小肠，使其内容物通过无菌套膜挤出肠腔，待小肠内压力明显减轻，肠壁张力明显减轻后，用直线型切割吻合器沿肠壁横行切除穿孔部肠壁，并用3-0可吸收线加强褥式缝合，调整胃管，吸取腹腔内液体，反复用温盐水及甲硝唑冲洗腹腔，见腹腔内液体颜色变淡。

4．手术野彻底止血，再次检查腹腔内其他脏器未见损伤后，留置盆腔引流管，逐层关闭腹腔。

5．手术经过顺利，术中出血约20ml，术中病人血压平稳，麻醉效果满意，安返病房。

记录医师：
审核医师：。

许昌市公疗医院
许昌市中心医院南院区
剖宫产手术记录
姓名：年龄：床号：住院号：
术前诊断：
术后诊断：
手术名称：
手术医师术者一助二助
麻醉方式：麻醉者：器械护士：
手术时间年月日时分开始时分完毕共用时分
手术经过
体位切口下腹正中纵耻骨联合上横切口 cm
原手术瘢痕有无剔除是否
探查子宫下段形成粘连情况
胎方位先露高低：高浮浮浅定深定
切开方式下段横切其它
切开方法撕开撕+剪
羊水性状清Ⅰ°Ⅱ°Ⅲ°羊水量 ml
娩出方式手取胎吸产钳宫缩剂
胎儿体重 kg Apgar 评分脐带 cm
胎盘胎膜情况完整粘连胎盘大小 cm
子宫收缩佳欠佳
子宫肌壁缝合反折腹膜连续间断
双侧附件绝育方式
术中特殊情况
麻醉效果满意不满意其他
腹壁切口连续皮内缝合间断缝合拆线需否
术中出血量 ml 输血量 ml 输液量ml 尿量ml
术后血压 / mmHg 脉搏次/分呼吸次/分
术中标本送病理
手术者记录者。

妇科剖腹产探查手术记录范文英文回答：My experience with gynecological cesarean section exploratory surgery was both challenging and rewarding. This type of surgery involves making an incision in the abdomen to access the uterus and surrounding organs. The purpose of the procedure is to investigate and address any potential issues or complications that may have arisen during or after childbirth.During the surgery, I was able to witness firsthand the skill and expertise of the surgical team. The surgeon meticulously examined the uterus and fallopian tubes, checking for any abnormalities or signs of infection. The team communicated effectively, using medical terminology and clear instructions to ensure the smooth progress of the operation.One particular moment that stood out to me was when thesurgeon discovered a small tear in the uterus that had gone unnoticed during the initial cesarean section. This tear could have potentially led to serious complications if left untreated. The surgeon skillfully repaired the tear, ensuring the safety and well-being of the patient.Another aspect of the surgery that impressed me was the use of advanced technology. The surgical team utilized laparoscopic instruments, allowing for a minimally invasive approach. This not only reduced the risk of complications but also facilitated a quicker recovery for the patient.Overall, the gynecological cesarean section exploratory surgery was a challenging yet fulfilling experience. It highlighted the importance of thorough examination and attention to detail in ensuring the best possible outcome for the patient.中文回答：我参与的妇科剖腹产探查手术经历既具有挑战性又令人满意。

1.患者姓名*** 住院号******** 病房号术前诊断：子宫肌瘤术中诊断：多发性子宫肌瘤拟行手术名称：次全子宫切除术实施手术名称：次全子宫切除术麻醉方法：腰硬联合麻醉麻醉者：**术者：** 助手：*** ***洗手护士：** * 巡回护士：**手术日期：*年*月*日开始时间：11：25 术毕时间：12：20腰硬联合麻醉置管成功后，患者仰卧于手术台上，强力碘消毒外阴及尿道，留置导尿管，初试麻醉平面后，强力碘消毒下腹部手术区域皮肤，铺无菌手术巾、单。

麻醉生效后，取下腹耻骨联合上2厘米横行切开皮肤长约10厘米，逐层切开腹壁各层达腹腔，洗手探查见：子宫增大，约11×9×8厘米大小，形态不规则，表面光滑，与周围组织无粘连，于子宫前壁可触及一5×5厘米的肌瘤结节，于子宫后壁近峡部可触及一直径约2厘米的肌瘤结节，于子宫底部偏左侧亦可见一直径约1厘米的肌瘤结节，向浆膜下突起，双侧附件外观未见异常。

术中诊断：多发性子宫肌瘤，故按原计划行次全子宫切除术。

拉钩暴露术野，纱垫排开肠管。

两把直钳夹持双侧宫角，上提子宫，Ligasure钳夹、电凝、剪断双侧子宫圆韧带，剪开膀胱子宫反折腹膜，下推膀胱至宫颈内口处，以Ligasure钳夹、电凝、剪断双侧卵巢固有韧带及输卵管峡部，再以Ligasure钳夹、电凝、剪断双侧宫旁组织、子宫动静脉，于宫颈内口处水平分别置扣克钳，切除子宫体。

艾利斯钳夹宫颈断端，强力碘、酒精消毒宫颈断端，10号丝线间断缝扎宫颈断端，10号丝线缝扎双侧扣克钳夹持组织，检查断端无出血及渗血，4号丝线连续缝合前后腹膜，包埋断端。

再次检查无活动性出血及渗血，清拭盆腹腔，清点器械纱布如数，逐层关腹，术终。

术中经过顺利，麻醉满意，出血约100毫升，血压脉搏平稳，术中输液1000毫升，留置尿管通畅，尿色清，量约100毫升。

术后患者安返病房。

测血压：100/60毫米汞柱，脉搏92次/分。

大体标本：剖开子宫见前壁一5×5×4厘米的肌瘤结节，向粘膜下突出，于子宫后壁近峡部肌壁间可见一直径约2厘米的肌瘤结节，均送病理检查。

住院号：001303 门诊号：___手术时间： 20:00 记录时间：20:00姓名：许性别：男年龄：73岁术前诊断: 1、消化道穿孔； 2、肠梗阻；3、急性阑尾炎；术后诊断：1、小肠梗阻并坏死穿孔； 2、弥漫性腹膜炎手术方式：剖腹探查术、小肠梗阻减压并肠穿孔修补术、小肠坏死切除肠肠吻合手术者：李助手：、、麻醉药物：复麻液麻醉师：手术及病理情况：置病人仰卧位于手术床,麻醉成功后,常规消毒手术区域并铺巾单,贴手术膜;取剑突下正中切口,长约10cm,依次切开皮肤、皮下组织、肌肉、腹膜入腹;探查：肝、胆、脾、胰腺、胃及十二指肠光滑未见破溃穿孔,幽门前浆膜层有×陈旧性瘢痕;腹盆腔位置咖啡色粪水样积液,吸净吸出液体约400ml,探查盲肠、升结肠、横结肠、降结肠、乙状结肠无扩张及穿孔;沿结肠系袋找到回盲部,见阑尾较长并充血水肿,分束切断结扎阑尾系膜,剧阑尾根部处切断阑尾,并予双结扎;残端用碘伏和酒精处理并荷包包埋;自屈氏韧带开始逐渐探查,见空肠明显扩张,自下逐步加重,至回肠段高度扩张,内有大量积液,在回肠远段可见两处穿孔约×,相距15cm,其中一处全层穿孔,有肠液溢出,一处粘膜层穿孔,浆膜层透亮;自全层穿孔后进入吸引器吸头,吸出大量肠液,约1500-2000ml,扩张小肠恢复原状,分别予以粘膜层和浆膜层缝合修补两处穿孔点;再距远段穿孔点约20cm处小肠可见坏死段约8cm长,肠管发黑热敷无活力,坏死段中央小肠壁见一同心圆形套叠解开状痕迹,决定行坏死段小肠切除吻合,取两把无损伤肠钳,在越过两侧肠坏死界限约2cm处将两侧肠管夹住,分离结扎切断坏死段小肠系膜,距两侧坏死界限处切除坏死小肠,生理盐水棉球擦拭干净并新洁尔灭棉球消毒残端,行端-端吻合,分别自对端肠壁两侧用1丝线各作一缝合固定牵引线,行粘膜层和浆膜层缝合,确认吻合口通过顺畅无渗漏、吻合段小肠血运好;生理盐水及甲硝唑溶液冲洗腹腔,见无活动性出血及肠漏;自左右下腹壁各做一引流穿孔,戳孔引出接引流袋后固定;清点纱布器械无误后,逐层关腹;手术顺利,麻醉满意,术中出血约50ml,术后安返病房;标本向家属展示后送病理;术后医嘱已下;手术者签名：。

肝破裂剖腹探查术手术记录范文英文回答：The patient, a 45-year-old male, was admitted to the hospital with complaints of severe abdominal pain, nausea, and vomiting. Upon physical examination, the patient appeared pale and had signs of hypovolemic shock. Laboratory tests revealed a significant drop in hemoglobin levels, indicating internal bleeding. Further imaging studies, including CT scans, confirmed the presence of a liver rupture.Surgery was immediately scheduled to address the liver rupture. The patient was taken to the operating room and placed under general anesthesia. A midline incision was made, and upon entering the abdominal cavity, a large amount of blood was observed. The liver was found to have a deep laceration, which was actively bleeding. The bleeding was controlled, and the area was thoroughly irrigated to remove any blood clots or debris.The extent of the liver injury required a partial hepatectomy, in which the damaged portion of the liver was resected. Hemostasis was carefully achieved, and the remaining liver tissue appeared viable. A thorough exploration of the abdominal cavity was performed to ensure that there were no other sources of bleeding or injuries.After confirming that there were no additional injuries, the abdominal incision was closed in layers. A drain was placed near the liver to monitor for any ongoing bleedingor fluid accumulation. The patient tolerated the procedure well and was transferred to the intensive care unit for postoperative monitoring.The patient's recovery in the postoperative period was uneventful, with stable vital signs and no signs of ongoing bleeding. He was gradually transitioned to a regular diet and physical therapy to aid in his recovery. Follow-up imaging studies showed satisfactory healing of the liverand no signs of complications.中文回答：这名45岁男性患者因严重腹痛、恶心和呕吐而被送入医院。