DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute suppurative appendicitis.
OPERATION PERFORMED: Laparoscopic appendectomy.
SURGEON: John Doe, MD
ANESTHESIA: General inhalation anesthesia.
FINDINGS:
1. The appendix was thick and indurated and erythematous with a fibrinous exudate throughout the distal one-half of the appendix. There were no gangrenous tract areas. There was no pus or abscess seen. The appendix was located behind the cecum in the retrocecal position, subserosal.
2. Inside the pelvis, there was about 50 mL of serosanguinous-type fluid that was suctioned out.
3. Small intestine, normal.
4. Large intestine, normal.
5. Omentum, normal.
6. Liver and gallbladder, normal.
7. The stomach looks normal.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMEN: Appendix.
HISTORY: This is a (XX)-year-old Hispanic male with abdominal pain of 1 day’s duration with associated nausea and vomiting. Started to generalize and localize to his right lower quadrant. He had 17,000 white count with a CT scan positive for appendicitis. On physical exam, with tenderness in his right lower quadrant, guarding and rebound in his right lower quadrant with McBurney and Rovsing sign. He was admitted to the hospital, given IV antibiotics and IV fluids, and was taken to the operating room for appendectomy. Informed consent was obtained for appendectomy.
DESCRIPTION OF OPERATION: The patient was taken back to the operating suite and placed under general inhalation anesthesia. The patient was sterilely prepped and draped in the usual fashion. Foley catheter was used to decompress the bladder, orogastric tube used to decompress the stomach, 0.5% Marcaine with epinephrine infiltrated on his skin as a local anesthetic.
A semilunar subumbilical incision was made with a scalpel and dissection progressed down to the umbilical fascia using hemostats. The fascia was grasped up and a Veress needle was inserted in the abdomen, tested with water drop test. The abdomen was insufflated with CO2 gas. A 10 mm trocar was placed in the abdomen and 5 mm laparoscope placed in the abdomen.
Upon initial examination, the abdomen findings were noted as above. Under direct visualization, two 5-mm ports were placed in suprapubic and right lower quadrant area. Using a combination of sharp and blunt dissection, the cecum and part of the ascending colon was mobilized so we could access the appendix. It was then dissected free from the cecum using sharp dissection. The mesoappendix was taken down with sharp dissection and looped with an Endoloop. The base of the appendix doubly looped with Endoloop and base of the appendix ligated, placed in the Endopouch and brought out through the umbilical incision.
The base of the appendix was fulgurated to remove any remaining glands. The area was then irrigated with sterile saline and there was noted to be good hemostasis. No evidence of any bowel injury. The abdomen was desufflated. Ports were removed. Laparoscope was removed. The umbilical fascia was approximated with a figure-of-eight suture of 0 Vicryl and the skin was approximated with 4-0 Monocryl in subcuticular fashion. Steri-Strips were applied over the incision site. The patient tolerated the procedure well and was taken to postanesthesia care unit in stable condition. All packs, instruments, and needles were accounted for.
