Surgical Notes

Pre-operative, operative, and post-operative surgical documentation

Pre-Operative Assessment
Signed

Breast lumpectomy + SLNB

Sunita Bose, 52F · UH-2026-0727 · Dr. A. Sharma · 22 Jun 2026

Patient fit for general anaesthesia. Informed consent obtained. Site marked — left breast, 2 o'clock position, 3 cm from nipple. NPO from midnight. IV access secured. Prophylactic antibiotics ordered.
Operative Note
Signed

Laparoscopic cholecystectomy

Arun Kumar, 48M · UH-2026-0788 · Dr. V. Srinivas · 23 Jun 2026

Patient positioned supine under GA. Standard 4-port laparoscopic technique. Critical view of safety achieved. Cystic duct and cystic artery clipped x2 and divided. Gallbladder retrieved in retrieval bag. Intraoperative cholangiogram — no CBD stones. Pneumoperitoneum released. All port sites closed. EBL: < 50 mL. Specimen sent for histopathology.