Sample Report: Laparoscopic Cholecystectomy
PREOPERATIVE DIAGNOSES
1. Cholelithiasis.
2. History of paroxysmal atrial tachycardia.
POSTOPERATIVE DIAGNOSES
1. Cholelithiasis.
2. History of paroxysmal atrial tachycardia.
PROCEDURES PERFORMED
1. Laparoscopic cholecystectomy.
2. Hasson cannula insertion.
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in the supine position. After placement of pneumatic compression devices, a Foley catheter, and orogastric tube, the patient had undergone satisfactory induction of general endotracheal anesthesia. The abdomen was prepped and draped using a Betadine preparation and sterile drapes. The patient had had a previous TAH/BSO and had a very long vertical midline incision. A cutdown was, therefore, performed at the infraumbilical position. Significant scar tissue was entered. The peritoneum was entered between hemostats, and finger dissection freed any intraabdominal adhesions. Then 0 Vicryl was placed for tacking sutures, and a Hasson cannula was inserted. A pneumoperitoneum was created without difficulty.
At this point, the 10-mm, 0-degree laparoscope was inserted. Two 5-mm trocars were placed under direct vision, one in the right anterior axillary line and one in the right midclavicular line. A second Veress port was placed in the left midline subxiphoid position. Gallbladder grasping forceps were used to grasp Hartmann pouch and the fundus of the gallbladder. A Maryland dissector was used to identify the gallbladder-cystic junction. No palpable stones were noted. The cystic duct appeared to be quite small. This was then doubly clipped and singly clipped proximally, and the cystic artery was similarly dealt with. The gallbladder was removed from the liver bed with electrocautery dissection. No spillage of bile or blood was appreciated.
The camera was applied to the subxiphoid port. The gallbladder was grasped with forceps and delivered through the umbilical wound without any contamination. The trocars were removed under direct vision, without evidence of bleeding.
The umbilicus was closed with interrupted sutures of 0 Vicryl. The skin was closed with 4-0 Vicryl in a similar fashion.
All sponge and needle counts were correct. The patient tolerated the procedure well and left the operating room in satisfactory condition.