DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Chronic cholecystitis.
POSTOPERATIVE DIAGNOSES:
1. Chronic cholecystitis.
2. Dense adhesions up to the gallbladder.
OPERATION PERFORMED:
1. Laparoscopic cholecystectomy.
2. Lysis of adhesions.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 100 mL.
INDICATION FOR OPERATION AND FINDINGS: This is a (XX)-year-old female who had an extensive workup for abdominal pain. Ultrasound showed no stones. The patient’s HIDA scan showed a slightly below normal ejection fraction, and she had extensive workups. At the time of surgery, the patient had dense adhesions up to the gallbladder from the omentum that had to be taken down. This was quite difficult. They were deeply entrenched into the liver as well. We were able to free that up with some difficulty. The biliary tract anatomy was well identified. The cystic duct was seen down to its junction with the common bile duct. The cystic artery was isolated. All anatomy was well visualized.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. After adequate general endotracheal anesthesia, the abdomen was prepped and draped in a sterile fashion. The patient was given 1 gram of Rocephin intravenously. Next, 2 towel clamps were placed on either side of the umbilicus. An incision was made, and the Veress needle was introduced without any difficulty. The water drop test was positive. The needle was then attached to the CO2 insufflator and insufflated to a pressure of 15 mm. Next, the needle was removed and a 10 mm trocar was slowly and carefully introduced. The camera was placed with the introducer, and the abdomen was scanned. Three accessory ports were placed under direct visualization; one was placed in the subxiphoid region, one in the midclavicular line, and one in the midaxillary line. The patient was then placed in the reverse Trendelenburg position and rolled to the left.
The assistant then grasped the fundus of the gallbladder pushing above the dome of liver. There were dense adhesions up to the gallbladder and to the liver. These were taken down using blunt dissection and cautery. This took some time to get it freed up. We were able to finally get down to the area of the hepatoduodenal ligament. We had to cauterize the liver in several locations to control the bleeding. We were able then to dissect out the hepatoduodenal ligament. The cystic duct was identified and visualized down to its junction with the common bile duct. The entire biliary window was dissected out the cystic duct. The cystic artery was identified. There were no accessory bile ducts, and the anatomy was well visualized. Three clips were placed proximally on the cystic duct and one distally was divided. Two clips were placed proximally on the cystic artery and one distally was divided. The gallbladder was slowly and carefully taken off the liver bed using spatula cautery. Once it was free, the liver bed was checked. There was no bleeding or bile leak noted.
The gallbladder was then placed in the Ethicon pouch and brought out the umbilicus under direct visualization. The area was checked one final time. The right upper quadrant was irrigated and suctioned dry. Each of the ports was removed under direct visualization. The abdomen was desufflated. The fascia of the umbilicus was closed with #0 Vicryl suture. The skin incisions were closed with #4-0 Vicryl subcuticular sutures. It should be noted that each of the incisions and subcutaneous tissues were locally anesthetized with 0.5% Marcaine with epinephrine for a total of 24 mL. Dressings were placed, and the patient was taken to the recovery room in a satisfactory condition.
