DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Intra-abdominal abscess.
POSTOPERATIVE DIAGNOSIS:
Intra-abdominal abscess.
PROCEDURE PERFORMED:
Diagnostic laparoscopy with local abdominal exploration and drainage of intra-abdominal abscess.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal tube anesthesia.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS: Penrose drain placed intra-abdominally.
COUNTS: Correct.
INTRAOPERATIVE FINDINGS: Slightly murky, mostly serous fluid was drained from the abdomen.
CONDITION: Fair.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old woman, who has a history of brain injury. A CAT scan was obtained yesterday, which revealed multiple intra-abdominal abscesses. A drain was placed at this time with minimal output. The decision was made to proceed with an operative washout and drainage. Consent was signed and placed in the chart, and the family was aware of the procedure, alternatives, risks, and benefits.
DESCRIPTION OF PROCEDURE: The patient was transferred from the ICU to the operating room suite, placed on the operating table in the supine position. The patient remained intubated, and general anesthesia was then induced under standard anesthesia protocol. The abdomen was prepped and draped in the usual sterile fashion.
A 5 mm Kocher was then placed using Optiview system in the right upper quadrant. Access was gained into the peritoneal cavity, and pneumoperitoneum was then created. The laparoscope was inserted, and finding dense adhesions throughout the abdomen with inability to proceed laparoscopically, the trocar was removed, and the pneumoperitoneum was deflated.
A left lower quadrant paramedian incision was then made directly over the area of concern for the abscess. Dissection was carried down with Bovie cautery to the anterior abdominal wall fascia, and anterior sheath was then incised. The rectus muscles were split. The posterior sheath was grasped, incised, and access to the peritoneal cavity was gained in controlled fashion. There was a large amount of murky, serous fluid that was evacuated. Cultures sent at this time. The wound and abdomen were irrigated thoroughly. There were no other obvious loculations that could be reached safely, as there were very dense intra-abdominal adhesions. There was no bowel injury that was observed.
The wound was closed by reapproximating the anterior sheath with 1-0 Novafil running suture. The skin was reapproximated with skin staples. Iodoform wicks were placed, and prior to wound closure, a large Penrose drain was placed intra-abdominally and sewn in place with a Vicryl skin suture. Gauze and tape dressing was then applied. The patient tolerated the procedure well.
