Surgical note for perineal laceration Template

OPERATION NOTE
OPERATION Repair of third-degree perineal tear
SURGEON Dr. Emily Carter  
ANAESTHETIST Dr. John Smith  
ANAESTHETIC General anaesthetic  
INDICATION The patient, a 28-year-old female, sustained a third-degree perineal tear during vaginal childbirth.
FINDINGS The tear extended through the perineal muscles and involved the anal sphincter complex.
PROCEDURE
- Anaesthesia method: General anaesthetic was administered.
- Patient positioning: The patient was positioned in the lithotomy position.
- Preoperative preparation: The perineal area was cleansed and draped in a sterile fashion.
- Step-by-step account of the procedure: The tear was identified and the edges were refreshed. The anal sphincter was repaired using interrupted sutures. The perineal muscles were approximated with absorbable sutures. The vaginal mucosa was closed with continuous sutures.
- Medications administered: Prophylactic antibiotics were administered intravenously.
- Complications encountered and management: No complications were encountered during the procedure.
- Closure technique: The skin was closed with subcuticular sutures.
- Post-procedure examination: The repair was checked for hemostasis and integrity.
- Estimated blood loss: Approximately 150 ml.
PLAN
The patient will be monitored in the recovery room for 2 hours. Pain management will include oral analgesics. The patient is advised to avoid straining and to follow up in 2 weeks for a wound check.