DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis, perforated.
OPERATION PERFORMED: Laparoscopic appendectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: After the patient had a Foley catheter inserted in the emergency room, she was brought to the operating room and given general anesthesia. The patient was then prepped and draped in the usual sterile fashion in the supine position with the mid abdomen exposed. The area of the umbilicus was infiltrated with 0.5% Marcaine. A vertical incision was made sharply through the skin and carried down through the midline fascia under direct vision. A suture was placed in the midline fascia and a blunt port placed intraabdominally. The abdomen was insufflated to 15 mmHg pressure with CO2 and a camera placed. Some adhesions to the anterior abdominal wall were carefully taken down after placing a 12 mm port inferior to the umbilicus. Once this was performed, a 5 mm port was placed in the right lower quadrant.
An obvious appendix, that was acutely infected and slightly perforated, was identified in the right lower quadrant. This was carefully freed from the surrounding tissue, and using a stapling device, the base of the appendix was carefully freed from the mesentery and stapled. The remaining mesentery was then stapled, and the appendix was placed into a bag. The area was then copiously irrigated with normal saline, and hemostasis was obtained with electrocautery. After adequate hemostasis, the rest of the abdomen was inspected, and no other areas were seen which were abnormal or bleeding.
Once this was performed, then the camera was placed into the lower 12 mm port site and the bag grasped with a sharp instrument and drawn up to the umbilicus. This was then carefully removed. Once the bag was removed, the abdomen was reinspected for hemostasis. After assuring hemostasis, the abdomen was deflated and the ports withdrawn.
The umbilical and lower midline port sites were closed in two layers. The small right lower quadrant port site was closed in a single layer. Steri-Strips, a clean dry pressure dressing, and Tegaderm were applied, and the patient was taken to the recovery room in satisfactory condition.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Appendicitis.
POSTOPERATIVE DIAGNOSIS: Appendicitis.
PROCEDURE PERFORMED: Laparoscopic appendectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: Appendix.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old lady with right lower quadrant pain and CT proven appendicitis. We recommended that she undergo appendectomy. The risks, benefits, and alternatives have been discussed with her, and she has consented for surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. After undergoing anesthesia, her abdomen was prepped and draped in a standard sterile fashion using DuraPrep. A 5 mm Optiview trocar was placed in the supraumbilical position. The right upper quadrant and left lower quadrant trocars were placed. The appendix was grasped and elevated. It was indeed inflamed. We made a rent in the mesoappendix at the base of the cecum. A GIA stapler was used to staple the appendiceal artery. Another firing was used to transect the appendix and was placed in the bag and removed through the left lower quadrant trocar incision. We irrigated out and suctioned out the right lower quadrant, as well as some turbid fluid in the pelvis. Both staple lines were intact and hemostatic. The two working trocars were then removed. A 4-0 Monocryl was used to close the right upper quadrant and umbilical sites. On the left lower quadrant site, we used 0-Vicryl on the fascia and then a 4-0 Monocryl. Steri-Strips were applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.
General Surgery Sample Reports
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Appendicitis.
POSTOPERATIVE DIAGNOSIS: Appendicitis.
PROCEDURE PERFORMED: Laparoscopic appendectomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia, local 30 mL of 0.5% Marcaine with epinephrine.
FLUIDS: One liter of crystalloid.
ESTIMATED BLOOD LOSS: 5 mL.
COMPLICATIONS: None.
DISPOSITION: To the recovery room in stable condition.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who presents with an appendicolith, some mild right lower quadrant abdominal pain. Her appendix needs to be removed. Risks and benefits of surgical intervention were discussed with her. She states she understands these risks and is willing to proceed.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating room table in a comfortable supine position. General endotracheal anesthesia was administered. Compression boots were placed on the patient. A Foley catheter was inserted. The patient was given Ancef 1 gram IV piggyback perioperatively. The patient’s abdomen was prepped and draped in a sterile fashion.
We began by anesthetizing skin and subcutaneous tissues supraumbilically. A small stab incision was made. A Veress needle was placed in the peritoneal cavity. The abdomen was insufflated to a pressure of 15 mmHg. Gained access through a trocar, and the camera, we were able to get in without difficulty. Two other stab incisions were then made after anesthetizing the skin and subcutaneous tissues. A 12 mm trocar was placed in the left lower quadrant. A 5 mm trocar was placed in the right upper quadrant. Through these, we were able to grasp and dissect out the appendix. We were able to free it up down to its base. We fired a 45 vascular Endo GIA across the appendix and then another firing across the mesoappendix, transecting the appendix and the mesoappendix. We then put the appendix in a bag, brought it out through the left lower quadrant fascial defect. There were a couple of small bleeding points that were cauterized.
We irrigated and suctioned the abdomen dry. We were satisfied with hemostasis. We removed the trocars under direct visualization, deflated the abdomen of as much CO2 gas as possible, and closed the incisions with 4-0 Vicryl subcuticular sutures. Benzoin, Steri-Strips, and a sterile dressing were applied. Sponge and instrument counts were correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
