DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Biliary dyskinesia.
POSTOPERATIVE DIAGNOSIS: Biliary dyskinesia.
OPERATION PERFORMED: Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General anesthesia combined with endotracheal tube intubation.
SPECIMENS: Gallbladder.
COMPLICATIONS: None.
DRAINS: None.
ESTIMATED BLOOD LOSS: Minimal.
INTRAOPERATIVE FINDINGS: The gallbladder was noted to have a minimal amount of gallstones with some biliary sludge. No other pathology was noted. The gallbladder was not edematous or hyperemic. No adhesions were seen.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. General endotracheal anesthesia was then induced. A Foley catheter along with a nasogastric tube was placed. The patient’s abdomen was sterilely prepped and draped in the standard surgical fashion.
An incision was then made supraumbilically with an 11 blade knife. The fascia was then elevated and incised with entry into the peritoneal cavity. No bowel contents were visualized upon entry. After this, two simple interrupted sutures of 2-0 Vicryl were then taken. A 10 mm Hasson cannula was then placed and anchored and secured. The abdomen was then insufflated with carbon dioxide to a pressure of 250 mmHg. The patient tolerated the insufflation well. Additional working trocars were then placed within the epigastrium and along the right costal margin. A 30-degree laparoscope was then inserted, and the gallbladder was easily seen and shown to be somewhat distended, however, easily compressible.
At this time, the cystic duct wall and cystic artery were circumferentially dissected. An intraoperative cholangiogram, however, was not able to be completed due to the small size of the cystic duct. Once the decision was made, the cystic duct was then doubly clipped and ligated. The cystic artery was then dissected free and also doubly clipped and also ligated. The gallbladder was then taken off its peritoneal attachment with Bovie electrocautery from the gallbladder bed fossa. Hemostasis was obtained. The gallbladder was then removed with an EndoCatch bag through the umbilical trocar. The laparoscope was placed back into the abdominal cavity, and pneumoperitoneum was then recreated, and clips were again seen on the cystic duct and cystic artery with no leakage of bile or any blood from the cystic artery. Fossa was irrigated and then siphoned free.
The abdomen was then allowed to collapse. All skin incisions were closed with 4-0 Monocryl in running subcuticular fashion. The incisions were clean and dry along with the application of Steri-Strips and dry sterile dressings. The patient was awoken from anesthesia and transported to the recovery room in stable condition. All instrument, sponge, and needle counts were correct at the end of the case.
Sample #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Symptomatic cholelithiasis.
2. Chronic cholecystitis.
POSTOPERATIVE DIAGNOSIS:
1. Symptomatic cholelithiasis.
2. Chronic cholecystitis.
OPERATION PERFORMED: Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: None.
OPERATIVE FINDINGS: Acute cholecystitis with contracted gallbladder.
DESCRIPTION OF OPERATION: The patient was brought to the OR and placed supine on the operating table. After undergoing anesthesia, the patient’s abdomen was prepped and draped in surgical fashion using DuraPrep.
A 5 mm Optiview trocar was placed in the supraumbilical position. A 10 mm subxiphoid and two right lateral 5 mm trocars were placed. The fundus of the gallbladder was grasped and retracted up over the liver. The infundibulum was retracted inferolaterally. We dissected out the cystic duct and clipped it twice proximally and once distally and divided it. The cystic artery was controlled in the same fashion. The gallbladder was bovied off the liver bed with the spatula and removed through the subxiphoid trocar site. The liver bed was oozing somewhat. We controlled that with coagulation with cautery and Surgicel. We irrigated and suctioned out our irrigant.
The three working trocars and finally the camera trocar were removed. Fascia at the 10 mm subxiphoid site was closed with figure-of-eight 0 Vicryl and 4-0 Monocryl and Steri-Strips were used for the skin. The patient was awakened and transferred to PACU in satisfactory condition. The patient tolerated the procedure well.
