DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Biliary dyskinesia.
POSTOPERATIVE DIAGNOSIS:
Biliary dyskinesia.
OPERATION PERFORMED:
Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 25 mL.
COMPLICATIONS: None.
OPERATIVE FINDINGS: There were no adhesions. Gallbladder itself appeared reasonably normal, but there did appear to be a tiny stone within it once we opened it on the back table.
DESCRIPTION OF OPERATION: A small infraumbilical incision was used. The incision was deepened into the rectus fascia. The fascia was incised.
The abdomen was entered in usual fashion, and 2-0 Vicryl stay sutures were placed under direct vision. At this point, the abdomen was insufflated with 15 cm of pressure, and the patient was placed in reverse Trendelenburg. Three 5 mm ports were placed in the epigastrium, all under direct vision.
The fundus of the gallbladder was then grasped and flipped up and over the liver. The neck was retracted laterally and caudad, exposing the ductal structures, which were dissected out. The cystic duct was doubly clipped and transected as was the cystic artery.
The gallbladder was then removed from the gallbladder fossa using electrocautery. A small posterior branch was clipped as well. A small hole was made within the gallbladder allowing moderate bile spillage. Prior to complete removal of the gallbladder, the liver bed was then inspected and hemostasis was achieved with cautery. The gallbladder was then placed into an endoscopic bag and removed from the abdomen.
The ports were placed back into the abdomen. The right upper quadrant was reinspected and irrigated out with about 2 liters of sterile saline. There was no ongoing bleeding. No bile spillage.
Therefore, all the ports were removed under direct vision and infiltrated with local. The fascia and skin were infiltrated with local. The fascia was closed with 0 Vicryl suture and the skin with 4-0 Vicryl subcuticular suture, benzoin, and Steri-Strips. The patient tolerated the procedure well. There were no complications.
PREOPERATIVE DIAGNOSIS:
Acute cholecystitis.
POSTOPERATIVE DIAGNOSIS:
Acute cholecystitis.
OPERATION PERFORMED:
Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
SPECIMEN: Gallbladder and stones.
COMPLICATION: None.
ESTIMATED BLOOD LOSS: Minimal.
FINDINGS: Inflamed and thickened gallbladder.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the OR and prepped and draped in a sterile fashion. A small incision was made at the base of the umbilicus. Then, the abdominal cavity was entered through the umbilical defect. A 5 mm port was then placed through this umbilical defect and CO2 insufflation begun. After adequate pneumoperitoneum, two additional 5 mm ports were placed in the right upper quadrant, along with an 11 mm port in the subxiphoid area. The gallbladder appeared to be very thickened and inflamed, consistent with acute cholecystitis. At this point, a decompression needle was introduced, and a small amount of bilious fluid was then aspirated. Dissection began by peeling away the thickened peritoneum in the triangle of Calot, to reveal a cystic duct as it entered directly into the gallbladder. The cystic duct is clipped and divided. The cystic artery is seen just medial to the cystic duct in the usual location and also clipped and divided. The gallbladder was gently moved from the liver bed with cautery and retrieved through the subxiphoid port site into a specimen bag. The area of dissection was then irrigated with saline solution. Hemostasis was achieved with cautery. CO2 and irrigate were then aspirated. Ports were removed. The fascial defect at the umbilical and subxiphoid areas were reapproximated with 0 Vicryl. Skin was reapproximated with 4-0 Vicryl. The patient was returned to recovery in stable condition.
PREOPERATIVE DIAGNOSIS:
Acute calculus cholecystitis.
POSTOPERATIVE DIAGNOSIS:
Acute calculus cholecystitis.
OPERATION PERFORMED:
Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 30 mL.
COMPLICATIONS: None.
OPERATIVE FINDINGS:
1. White bile consistent with cystic duct obstruction.
2. Numerous gallstones.
3. Gallbladder wall thickening.
4. Final needle and sponge counts correct.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic female seen and evaluated in the office with intermittent abdominal pain. An ultrasound of the gallbladder revealed gallstones and gallbladder wall thickening suggestive of cholecystitis. The patient was scheduled for laparoscopic cholecystectomy.
DESCRIPTION OF OPERATION: The patient was brought to the operative room. She was positioned supine on the operative room table. Pneumatic compression stockings were applied and inflated. After induction of adequate general endotracheal anesthesia, the area over the abdomen was prepped and draped in the usual sterile fashion.
A small umbilical incision allowed for introduction of the Veress needle and insufflation of the abdomen to 15 cm of water pressure using carbon dioxide gas. The 0 degree, 5 mm laparoscope was introduced through a 5 mm port at the umbilicus, and 3 additional ports were placed in their usual anatomic positions. The gallbladder was found to be contracted and partially intrahepatic. Retraction of the gallbladder did allow for identification of the triangle of Calot. The cystic duct and cystic artery were both skeletonized. Two clips were used to control the cystic duct distally and one at the level of the gallbladder with good hemostasis and no evidence of a bile leak following transection. The cystic artery was controlled in much the same fashion, with good hemostasis following transection.
The gallbladder was then dissected away from the liver in what was felt to be an inflamed, less-than-optimal plane. Nonetheless, bleeding was controlled using low-wattage cautery, and blood loss was limited to 30 mL for the entire procedure. Once the gallbladder was freed from its attachments of the liver, it was placed in an Endocatch bag and brought out through the upper midline port site fascial defect. The upper midline fascia was closed using 0 Vicryl suture under direct vision with the aid of the Endo Close apparatus. The gallbladder fossa was irrigated with a small amount of normal saline, all of which was aspirated completely. Hemostasis was excellent at the end of the procedure.
Both lateral ports were removed under direct vision with good hemostasis at both sites. The omentum was tucked into the gallbladder fossa and the patient was repositioned supine. The abdomen was desufflated through the umbilical port, which was subsequently removed. All four incisions were infiltrated with Marcaine 0.25% with epinephrine and each incision was closed using 5-0 PDS suture in a subcuticular fashion. Dermabond skin glue was used to seal each of the 4 incisions.
The patient was awakened, extubated and moved to the recovery room in satisfactory condition. She tolerated the procedure well. There were no complications. Final needle and sponge counts were correct.
PREOPERATIVE DIAGNOSES:
1. Cholelithiasis.
2. Biliary colic.
POSTOPERATIVE DIAGNOSES:
1. Cholelithiasis.
2. Biliary colic.
OPERATION PERFORMED:
Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
OPERATIVE FINDINGS: The gallbladder wall was thickened. It was not acutely inflamed. There were numerous tiny 1 mm stones.
DESCRIPTION OF OPERATION: With the patient adequately anesthetized under general anesthesia, the abdomen was prepped and draped in the usual fashion. With the patient in steep Trendelenburg, an infraumbilical incision was performed. Dissection was performed down to the fascia, which was grasped with a towel clamp and elevated. A Veress needle was then inserted and the abdomen was inflated to 15 mmHg. The Veress needle was removed, and an 11 mm trocar was inserted in the epigastrium. A cursory inspection of the abdomen revealed no remarkable findings. The 5 mm trocars were then inserted into the anterior axillary line and the midclavicular line subcostally. A second 11 mm trocar was inserted in the epigastrium. The gallbladder was grasped and retracted cephalad. The cystic duct was bluntly dissected free from its surrounding attachments. After positively identifying the common bile duct, the cyst duct was doubly clipped and divided. The cystic artery branched just before its attachment to the gallbladder. Both of these branches were identified, clipped, and divided. Electrocautery was then used to remove the gallbladder from the gallbladder bed. Any bleeding vessels in the gallbladder bed were electrocauterized. The gallbladder was then removed through the umbilical wound under direct vision. Copious irrigation was performed of the right upper quadrant. A final inspection of the gallbladder bed revealed it to be dry. All free solution was sucked out of the abdomen and all trocars were removed. The umbilical fascia was closed with a figure-of-eight 0 Vicryl suture. All skin wounds were closed with 4-0 Vicryl subcuticular stitches. Steri-Strips were applied to the wounds, which were dressed, and the patient returned to the recovery room awake, extubated, and in stable condition. All counts were correct at the end of the case x2. There were no complications. Blood loss was minimal.
PREOPERATIVE DIAGNOSES: Cholelithiasis and chronic cholecystitis.
POSTOPERATIVE DIAGNOSES: Cholelithiasis and chronic cholecystitis.
OPERATION PERFORMED: Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
SPECIMEN: Gallbladder.
BLOOD PRODUCTS: None.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with classic biliary colic. She has had no complications of abnormal liver function tests, pancreatitis, and her common bile duct is normal by ultrasound.
OPERATIVE FINDINGS: The patient has evidence of pretty significant chronic cholecystitis with multiple adhesions adhered to the gallbladder. These were dissected free. The rest of the intra-abdominal anatomy is fairly normal.
DESCRIPTION OF OPERATION: After verbal and visual identification, the patient was placed in the supine position on the operating room table. Monitoring devices were applied along with pneumatic compressive stockings. Prophylactic antibiotics were given. An adequate level of general endotracheal anesthesia was established. The abdomen was then prepped with ChloraPrep and draped in a sterile fashion.
Marcaine 0.5% with epinephrine was used to infiltrate all port sites prior to their placement. The initial port was placed just above into the right of the umbilicus and the midportion of the right rectus abdominis muscle. In this location, a 5 mm Xcel port and a 0 degree 5 mm scope were used to do a direct abdominal entry under direct vision. Once access to the peritoneal cavity was established, insufflation was begun. Three additional ports were placed in standard location for laparoscopic cholecystectomy using an 11 mm port in the subxiphoid location and 2 5 mm ports on the right costal margin.
The gallbladder fundus was grasped with an atraumatic grasper. Multiple adhesions had to be taken down by blunt and sharp dissection along with electrocautery. Eventually, we identified the infundibulum, and this was then grasped and retracted inferior and laterally. Dissection was then begun in the angle of Calot. Cystic duct, cystic artery were all clearly identified, and the cystic artery and duct was dissected for approximately 2 cm. Two clips proximally and one clip distally were used to control both the cystic duct and cystic artery. Both were then transected with laparoscopic shears. The gallbladder was then removed from its fossa in a retrograde fashion using electrocautery. It was placed in an EndoCatch bag and extracted to 11 mm port site.
We then irrigated down the cavity with a copious amount of saline, and the area was aspirated dry. We inspected the gallbladder fossa and there was no bleeding or bile leak. Clips on the cystic duct and cystic artery appeared to be secured.
Briefly, explored the abdomen. There was no other evidence of overt pathology. The cystic ports were all then removed under direct vision. The skin edge was then approximated with inverted interrupted 4-0 Vicryl sutures. Steri-Strips and sterile surgical dressings were applied. The patient was then awakened from anesthesia, extubated, and transported to the recovery room. The patient tolerated the procedure well. No complications were encountered.
PREOPERATIVE DIAGNOSIS:
Gallstone pancreatitis.
POSTOPERATIVE DIAGNOSIS:
Gallstone pancreatitis, pending pathology.
OPERATION PERFORMED: Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was placed in a supine position on the operating table and general anesthesia induced. The abdomen was shaved, prepped with Betadine, and draped in the usual manner. Venodyne boots were in place. The patient was placed in Trendelenburg position. A 1 cm curved incision was made just below the umbilicus. The linea alba was grasped and a disposable Veress needle passed into the peritoneal cavity. After verifying its intraperitoneal position, carbon dioxide was insufflated through it to an intraperitoneal pressure of 15 mmHg. The laparoscope and camera were then introduced through a 10 mm cannula in this location and the entry of the abdomen examined. The gallbladder was mildly distended, but was not tense. The visualized portions of the liver, stomach, small and large intestine appeared normal. There was no inguinal hernia present.
The patient was then placed in reverse Trendelenburg position and attention directed to the right upper quadrant. The 5 mm cannulae were introduced through the anterior axillary and midclavicular lines in the right side. The gallbladder was grasped and retracted over the liver. Dissectors were introduced through a 10 mm cannula in the upper midline. The hepatoduodenal ligament was dissected. The cystic duct was isolated and traced from the gallbladder to the common duct. It was small in size and the ERCP had been done preoperatively. No cholangiogram was therefore performed. The cystic duct was lifted twice proximally and once distally across the gallbladder and then divided.
Further dissection revealed the cystic artery which was also similarly lifted twice proximally and once distally and then divided. The gallbladder was then dissected away from its bed on the liver using a combination of blunt dissection and cautery. During this dissection, small opening was made in the gallbladder and some bile came out. This was aspirated. Before detaching the gallbladder completely from the liver, we checked for hemostasis which was adequate. The gallbladder, after being freed, was placed within an endobag and retrieved through the epigastric port site.
The sub and suprahepatic areas were irrigated with saline until the returns were clear. The cannulae were withdrawn. The port sites were hemostatic. Marcaine 0.25% was infiltrated into all the port sites. The fascia was closed at the two midline openings with 0 Vicryl sutures using a J needle. The skin incisions were closed with 3-0 and 4-0 Vicryl subcuticular sutures. Steri-Strips and Band-Aid dressings were applied. Blood loss was minimal. Tape and instrument counts were reported correct. The patient tolerated the procedure well and was transferred to the recovery room in good condition.
