DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Hemoperitoneum.
2. Liver laceration.
3. Possible small bowel injury.
POSTOPERATIVE DIAGNOSES:
1. Hemoperitoneum.
2. Lacerations to left lobe of liver x2.
3. No bowel injury.
OPERATIONS PERFORMED:
1. Exploratory laparotomy for trauma.
2. Complex hepatorrhaphy x2.
SURGEON: John Doe, MD
ANESTHESIA: General via endotracheal tube.
ESTIMATED BLOOD LOSS: 850 mL.
FLUIDS: Four liters of lactated Ringer’s.
SPECIMENS: None.
COMPLICATIONS: None.
POSTOPERATIVE CONDITION: Stable to postanesthesia care unit.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gentleman who was involved in a motor vehicle accident this morning. He presented to the trauma bay and was noted to be tender with peritoneal signs on exam. A CT scan of his abdomen showed a laceration of the left lobe of his liver and free fluid. Also concerning, on his CT scan, were multiple thickened segmental loops of small bowel, which were suspicious for a small bowel injury. Given the patient’s seatbelt sign, we were concerned for a small bowel injury, and we thus brought the patient to the operating room for exploration.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed on the operating table in the supine position. General anesthesia was induced and he was intubated. The patient’s chest and abdomen were clipped of hair and prepped in the standard sterile fashion. He was draped in the standard sterile fashion as well. A surgical time-out was held, and the patient and the planned procedure were reconfirmed with all those present. The patient was given IV antibiotics.
An upper midline incision was made. This was carried down to the fascia which was grasped, elevated, and divided under direct vision. We entered the abdomen along the length of the incision. A moderate hemoperitoneum was noted, but there was no brisk bleeding. The falciform ligament was taken down between clamps and ties, and the extent of the falciform ligament was divided back toward the diaphragm. The Bookwalter retractor was placed for optimal viewing of intra-abdominal contents.
We began exploring the abdomen. We noted bleeding lacerations in the left lobe of the liver. There were two of these that were present, the lateral one on the liver, meaning in segment II, was noted to have brisk arterial hemorrhage. This was controlled initially with packing. We palpated his spleen and visualized this. There was no splenic laceration. Both diaphragms were intact. The anterior wall of the stomach and duodenum were intact. The small bowel was run from the ligament of Treitz to the ileocecal valve, visualizing the serosa of the small bowel in its entirety as well as the mesentery. There was no small bowel injury that was seen. The small bowel was then re-run to confirm this, and additionally, no small bowel injury or mesenteric injury was seen. The appendix was surgically absent. The cecum, transverse colon, left colon, sigmoid colon, and rectum down to the peritoneal reflection were then visualized. There was no hematoma present and no obvious injury present to these structures. There was no retroperitoneal hematoma present.
The right lobe of the liver was then examined. There was no injury present to this. Attention was turned to the left lobe of the liver, to the liver lacerations. One was in segment II on the anterior and posterior side of the liver. The other was in segment III, and this was entirely on the posterior side of the liver, aiming down toward the left hepatic vein. The more lateral one in segment had brisk arterial hemorrhage, which had been controlled with packing. The one in segment III was mostly venous in nature. This was controlled with a complex hepatorrhaphy technique consisting of serial applications of argon beam coagulation followed by Surgicel, followed by a coating of FloSeal. These controlled each of the liver lacerations nicely. We made a search for bleeding and found no additional bleeding. We checked the liver lacerations again, and they were not bleeding.
The hemoperitoneum was suctioned completely. We watched for return of the hemoperitoneum and did not find any. We then prepared for closure. Closure was accomplished with a running #1 PDS suture, sewn from above and below, and tied in the middle in the anterior abdominal fascia. After irrigation, the wound was closed with surgical staples. A sterile dressing was applied. The patient remained intubated but was transferred to the recovery room under the care of anesthesia and surgical staff in stable condition. There were no complications. Needle, sponge, and instrument counts were each correct as reported to us by the nurse in charge at the termination of the case.
