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Laparoscopic Cholecystectomy Medical Report Example

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Symptomatic cholelithiasis.

POSTOPERATIVE DIAGNOSIS:
Symptomatic cholelithiasis.

OPERATION PERFORMED:
Laparoscopic cholecystectomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal.

SPECIMEN:  Gallbladder with stone.

DESCRIPTION OF OPERATION:  The patient was placed in the preoperative holding area. Risks, benefits, indications and alternatives were discussed. All of the patient’s questions were answered and the patient voiced verbal understanding and elected to proceed. The patient was taken to the operating room and was placed on the operating room table in the supine position. The patient had just voided prior to surgery, so a Foley catheter was not placed. General endotracheal anesthesia was then induced. The patient was then prepped and draped in the normal sterile fashion. At that time, a final time-out was performed, which indicated the patient, medical record number and date of birth were verified and all equipment for a laparoscopic cholecystectomy was present in the room. All parties present acknowledged and agreed.

The operation was begun by injecting a local anesthetic solution of 0.5% Marcaine with epinephrine in an infraumbilical position. The skin was then grasped on both sides of the midline with Adson forceps. A skin incision was made in a vertical manner. Blunt dissection down to the anterior abdominal wall was done. Kocher clamp was then used to grasp the base of the umbilicus. The muscles were split in the midline raphe into the wound. A transverse incision was then made with a #11 blade knife. This gained access into the peritoneal cavity. Two stay sutures were placed with 3-0 Vicryl on the UR-6 needle. A Hasson trocar was then inserted through the fascial defect and secured with the stay sutures. Pneumoperitoneum was done, which was 15 mmHg and initial inspection of the abdomen was done with a 0 degree 10 mm scope. There was no evidence of visceral or vascular injury.

Upon entering the abdomen, routine diagnostic laparoscopy had findings mentioned above. Focus was then placed on placing three more ports; one was a subxiphoid 11 mm port and then two 5 mm ports, one at the midclavicular line and one at the anterior axillary line. These were all placed in the same manner as follows. Local anesthetic was used to identify the location within the peritoneal cavity with direct visualization. Local anesthetic was then injected into the peritoneum and then into the subcutaneous tissues and subcutaneously. A skin nick was then made with a #11 blade knife. This was explored using a hemostatic clamp. Appropriate size trocars were placed as mentioned previously. These were watched under direct visualization. There was no evidence of injury or problems entering the abdomen. Two graspers were used through the right lateral ports and used to hold the fundus of the gallbladder cephalad and the infundibulum of the gallbladder caudal and laterally to the patient's right. This exposed Calot triangle and peritoneum was opened around the infundibulum of the gallbladder, eventually exposing the cystic duct. The cystic duct was circumferentially dissected bluntly. Two clips were placed proximally and then one clip distally. There were some lateral structures that appeared to be a cystic artery. It was circumferentially dissected and then two clips were placed proximally and one clip was placed distally. It was then transected with Endoshears. Further dissection was then done with hook electrocautery.

As we approached the posterior area of the infundibulum, there was another structure identified that appeared to be a blood vessel. It was circumferentially dissected and a clip was placed proximally and distally. It was then transected with Endoshears. It did have a lumen that was consistent with likely a posterior branch of the cystic artery. This artery was clearly seen traversing only to the gallbladder from its current location. Once it was identified as an artery, a clip was placed proximally, to make two clips on the proximal end of this artery. Hook electrocautery was then used and the gallbladder was taken off the liver bed. There were some small areas of oozing, but these were controlled easily with electrocautery. Final visualization before the gallbladder came off was made of the liver bed. Hemostasis was ensured. The gallbladder was then taken off and an EndoCatch bag was placed through the subxiphoid port. It was then grasped through the infraumbilical port and then pulled though the Hasson trocar and then the Hasson trocar was removed and the gallbladder was removed. The fascial defect had to be enlarged, as well as the subcutaneous tissue, to accommodate this single large stone. The gallbladder was then removed and passed off the table as a specimen.

The trocars were then replaced and irrigation of the liver bed began. There was again good hemostasis and irrigation of the abdomen quickly cleared. This was suctioned dry. The three trocars were then removed under direct visualization without any bleeding. The Hasson trocar was then removed and the two stay sutures were removed. The 2-0 Vicryl on a UR-6 was used to make two figure-of-eight stitches at the umbilicus to close the transverse incision. The wounds were then irrigated and dried. The skin was closed with interrupted 5-0 Monocryl. Skin was then washed and dried. Mastisol and Steri-Strips were placed on the top as an outer dressing for all but the infraumbilical port. This concluded the operation. The patient was extubated in the operating room without difficulty and was taken to the postanesthesia care unit in stable condition. There were no known apparent complications during the procedure or immediately after. All laparoscopic instruments, needles and sponges were counted and correct at the end of the procedure.