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Laparoscopic Ileocolic Resection Medical Dictation Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Terminal ileum carcinoid.

POSTOPERATIVE DIAGNOSIS:
Terminal ileum carcinoid.

OPERATION PERFORMED:
Laparoscopic ileocolic resection.

SURGEON:  John Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  50 mL.

DRAINS:  None.

SPECIMEN:  Terminal ileum, right colon.

CONDITION:  The patient tolerated the procedure well.  There were no complications.  He was extubated in the operating room and transferred to the PACU in stable condition.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and laid supine on the operating room table.  Once general endotracheal anesthesia was obtained, the patient was placed in the lithotomy position.  An infraumbilical midline incision was created in order to insert a 12 mm trocar infraumbilically.  Once this was passed into the abdominal cavity, insufflation was attached to the trocar and adequate pneumoperitoneum was obtained.

The laparoscope was then inserted into the abdomen, and there was a 12 mm trocar that was inserted in the left lower quadrant, a 5 mm trocar in the right lower quadrant, and a 5 mm trocar in the left upper quadrant.  With the use of the trocars, graspers and the Harmonic scalpel were used to mobilize the terminal ileum and the right colon off the white line of Toldt.  Once there was adequate medial mobilization, the Babcock grasped the cecum in the midline trocar to allow the ileocolic resection to be performed extracorporeally.  The pneumoperitoneum was then released and the infraumbilical incision was extended around the umbilicus and inferiorly.  The fascia and the peritoneum were also divided with electrocautery.

The terminal ileum was then grasped and delivered extracorporeally.  A portion of the terminal ileum was transected approximately 10 cm proximal to the ileocecal valve.   The ileocolic vessels were divided with electrocautery.  The ileocolic vessels were then grasped with a long Kelly.  They were transected and then they were tied with 2-0 silk sutures.  The mesentery of the right colon was also divided with Kelly clamps and 2-0 silk sutures.  The proximal transverse colon was then sutured with the terminal ileum in a side-to-side fashion.  A colotomy and enterotomy were created in order to accommodate a 75 mm GIA stapling device.  Once the stapler was introduced, it was secured, fastened, and fired.  This created a side-to-side and end-to-end functional anastomosis.  The colotomy was then stapled with a 55 mm TA stapling device.  A cross-suture was placed with a 3-0 silk suture.  The enterotomy that was transected with the TA was imbricated with multiple 3-0 silk sutures.  The mesentery was reapproximated with multiple 3-0 silk sutures.

The newly anastomosed bowel was then reintroduced into the abdominal cavity.  The abdomen was copiously irrigated and dried.  There was adequate hemostasis.  A #0 Prolene suture was then used to reapproximate the fascia, one running from the inferior portion of the wound, one from the superior portion of the wound, meeting in the middle and being tied together.  The subcutaneous tissue was copiously irrigated and dried and the skin was reapproximated with skin staples.  The trocar sites were reapproximated with 4-0 Vicryl suture in a subcuticular fashion.  The 12 mm trocar site at the fascia was reapproximated with a 0 Vicryl suture.  The skin was also reapproximated with a 4-0 Vicryl suture in a subcuticular fashion. This completed the procedure.  Needle, lap, and instrument counts were correct at the end.  The patient tolerated the procedure well.  There were no complications.  The patient was then extubated in the operating room and transported to the PACU in stable condition.

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