LAPAROSCOPIC CHOLECYSTECTOMY OPERATIVE SAMPLE REPORT
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute on chronic calculous cholecystitis.
POSTOPERATIVE DIAGNOSIS: Acute on chronic calculous cholecystitis.
PROCEDURE PERFORMED: Laparoscopic cholecystectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 10 mL.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old male admitted to the emergency room last night with chest pain radiating into his back. Cardiac workup was performed and found to be negative. CT scan demonstrated large gallstone with gallbladder wall thickening and pericholecystic fluid. Followup ultrasound confirmed the diagnosis.
The patient was seen and found to have clinical symptoms and signs consistent with cholecystitis. We consented him for laparoscopic cholecystectomy. We discussed in detail technical aspects of the procedure as well as possible complications, the risks and benefits of the procedure as well as outcomes without the surgical procedure. The patient wished to proceed, consented, and requested that we proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR. He received IV antibiotics preoperatively. SCDs were applied to his lower extremities. A general anesthetic was administered. He was endotracheally intubated. A Foley catheter was placed in the urinary bladder. The abdomen was prepped and draped in the usual sterile fashion.
A 1 cm incision was made in the umbilicus after instillation of local was carried down to the level of the fascia. The fascia was incised, and a blunt-tip trocar was introduced into the abdominal cavity followed by inflation of the abdominal cavity with 15 mmHg. Camera was introduced through the trocar. Intra-abdominal contents were inspected. There was no evidence of injuries at the entry site. The gallbladder was found under the right lobe of the liver, covered with omental adhesions.
Additional trocars were placed at the subxiphoid and lateral positions. Omental adhesions were taken down with combination of blunt and electrocautery dissection, and the fundus of the gallbladder was grasped and elevated. The omental adhesions were taken off the body and off the infundibulum. The infundibulum was found to have large impacted stone. It was grasped with forceps and splayed laterally. The porta hepatis was dissected exposing the gallbladder-cystic duct junction as well as cystic artery.
The cystic duct was divided by placing a clip at the gallbladder-cystic duct junction. Then, additional clips were placed on the mid cystic duct with care taken to avoid injury to the common bile duct. The cystic duct was then divided between clips. The cystic artery was divided in a similar fashion. The gallbladder was then dissected away from the liver using electrocautery. There was no spillage of bile or stones. Gallbladder was then placed in the Endobag and removed from the abdominal cavity without spillage of bile or stones.
The liver and gallbladder fossa were irrigated with a copious amount of saline, was closely inspected, and was found to be completely hemostatic. Cystic duct remnant and cystic artery remnant were inspected closely for evidence of bleeding or bile leak. None was identified. The area was irrigated once again, aspirated dry, and then reinspected. There was no evidence of any bile leak or bleeding from the liver.
All instruments were removed. The abdomen was deflated. All wounds were closed in layers using interrupted 0 Vicryl for the fascia and Monocryl for skin. Sterile bandages were applied. The patient was awakened and extubated in the operating room, moved to recovery room in satisfactory condition. All sponge and instrument counts were reported correct. There were no complications and only minimal bleeding.
