DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
OPERATION PERFORMED: Laparoscopic appendectomy.
SURGEON: John Doe, MD
ESTIMATED BLOOD LOSS: 5 mL.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This is a (XX)-year-old who has been sick for about 20 hours with mid abdominal pain, nausea, vomiting, a bit of diarrhea, here in the emergency room late last night, and early this morning tender in the right lower quadrant. White count was 17,000 to 18,000. CT scan showed a dilated inflamed appendix.
DESCRIPTION OF OPERATION: The patient was placed on the operation table in the supine position. General anesthesia was induced, and endotracheal tube was used. The abdomen was prepped with DuraPrep. He had just voided in the holding area. No Foley catheter was placed. The abdomen was draped.
A 10 mm vertical incision was made in the base of the umbilicus. Veress needle was advanced, and the abdomen was insufflated. A 12 mm trocar actually replaced this. Endoscope was advanced down. The patient was placed in Trendelenburg and rolled slightly to the left. The cecum was pulled up, and the appendix was obviously acutely inflamed, but not perforated. A 5 mm trocar was placed in the lower midline and 5 mm trocar in the left mid abdomen. The scope was switched to this port, and we worked through the other two sides.
An opening was made in the mesoappendix after we took down some lateral attachments of the appendix and cecum. The Endo- GIA with a vascular load was fired across the mesoappendix. It was left in place for 45 seconds to a minute and then released. Little bleeding was controlled by means of electrocautery. We cleaned off the cecum at the base of the appendix to use the Endo- GIA again; this time with a bowel load and fired it across without difficulty. We had to use a little electrocautery again.
The appendix was removed through the umbilical port sites. That trocar was replaced. The right lower quadrant was reinspected, irrigated, and suction dried. The pelvis was suction dried as best we could. The patient was brought back to neutral position and again all fluid that we could see was suctioned dry off the liver. The fluid of the lateral liver was suctioned out. The liver and gallbladder appeared normal. The rest of the bowel that we could see appeared normal.
The trocars were removed. The abdomen was deflated with a Valsalva maneuver. The fascia of the umbilical port site was closed with interrupted 0 Vicryl, and the skin of all three incisions was closed with running subcuticular stitch and 4-0 Vicryl. Steri-Strips were placed on the skin and Band-Aids over that. The patient was awakened, extubated, and taken to the recovery room.
