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Laparoscopic Appendectomy Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Acute appendicitis.

POSTOPERATIVE DIAGNOSIS:  Acute appendicitis.

OPERATION PERFORMED:  Laparoscopic appendectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room and laid in the supine position. Appropriate monitors were applied. The patient was intubated and general anesthesia was achieved. The patient had voided prior to entering the operating room. Incision was made at the umbilicus. Veress needle was placed and a pneumoperitoneum was established. A 5 mm bladeless trocar was placed into the abdomen. Diagnostic laparoscopy was performed. Next, a suprapubic incision was made, and a 5 mm bladeless trocar was placed into the abdomen under laparoscopic visualization. Then, the laparoscope was placed into this port site and the umbilical port site was replaced with a 12 mm bladeless trocar. An additional 5 mm bladeless trocar was placed in the left lower quadrant area. The patient was placed in Trendelenburg. Diagnostic laparoscopy was performed. There were no abnormalities noted except for acute appendicitis. There was no evidence of perforation. The appendix was densely adhered to the sidewall and these adhesions were taken down under direct visualization, lifting the appendix up in the air and then incising the peritoneum with laparoscopic scissors and then bluntly reflecting the appendix away from this area. Great care was taken not to dissect in the retroperitoneal area. This was done to free up the appendix up to the area of the cecum. The terminal ileum, which was adherent to the mesoappendix, was also incised and freed up. 

With the appendix able to be visualized, it was grasped and lifted up in the air with a soft bowel grasper and then a window was made in the mesoappendix just adjacent to the appendix with its junction with the cecum. Once this area was cleared off, it was then divided using an endoscopic 45 mm linear stapler. A white cartridge was used for this portion. The stapler was clamped down and left in place for approximately 30 seconds and then the bowel was divided. The mesoappendix was opened up further by incising the peritoneum. A window was made in the mesoappendix and it was divided using gray cartridges for the division. During this division, there was some bleeding from the staple line, which required electrocautery and also hemoclips. This area was irrigated thoroughly and inspected. All the staple lines were inspected. There was no active bleeding noted upon completion of this portion of the operation.

Next, the appendix was placed in an EndoCatch bag and brought out through the umbilical site. The colon closure device was then used to pass an 0 Vicryl suture to close this fascial defect. The trocars were replaced and the area again inspected and irrigated. There was no active bleeding noted from the staple lines. The excess irrigation was aspirated. Diagnostic laparoscopy was performed. There was no active bleeding noted, and there was no abnormal fluid collection noted. Next, the port sites were all infiltrated with 0.5% Marcaine with epinephrine. Approximately 20 mL of 0.5% Marcaine with epinephrine was utilized.  Pneumoperitoneum was released and the fascial suture was tied down and the skin was closed using 4-0 Vicryl in subcuticular fashion. Steri-Strips were applied and sterile dressing. The patient tolerated the procedure well without any complications. Estimated blood loss was approximately 30 mL. All the sponge counts were correct x2. The patient was taken to the recovery room in stable condition.