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Laparoscopic Cholecystectomy Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Gallstone pancreatitis.

POSTOPERATIVE DIAGNOSIS:
Gallstone pancreatitis.

OPERATION PERFORMED:
Laparoscopic cholecystectomy with intraoperative cholangiogram.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

SPECIMEN:  Gallbladder.

INDICATIONS FOR OPERATION:  The patient is an (XX)-year-old female who presented with signs and symptoms consistent with symptomatic cholelithiasis. The patient was confirmed on preoperative radiologic imaging and laboratory evaluation to have gallstone pancreatitis. After resolution of the patient’s pancreatitis, the decision was made to bring the patient to the operating room for laparoscopic removal of her gallbladder.

The risks and benefits of the procedure, including the possibility of bleeding, infection, bile duct injury, need for open operation, and worsening of her pancreatitis were reviewed in detail with the patient, and the patient agreed to proceed with surgery.

DESCRIPTION OF OPERATION:  After informed consent was obtained, the patient was brought to the operating room and placed on the operating table in the supine position. After induction of a general anesthetic, the abdomen was prepped and draped in the usual sterile fashion.

A small stab incision was made in the left upper quadrant through which a Veress needle was inserted. After establishing pneumoperitoneum, a 5 mm trocar was then placed in the right upper abdomen using Visiport technique. Under direct visualization with the 5 mm camera, an additional 5 mm trocar was inserted in the left abdomen, and some adhesions involving the umbilical area were cleared to allow placement of an 11 mm trocar site through this space.

A 10 mm, 0-degree laparoscope was then inserted through the umbilicus, and with the patient in reverse Trendelenburg position, an additional 11 mm trocar was inserted in the epigastrium to the right of falciform ligament. The fundus of the gallbladder was grasped and extended cephalad above the liver. Dissection in the infundibular area of the gallbladder revealed normal cystic duct and cystic artery anatomy. The cystic duct was clipped on the gallbladder side, and a small incision was made through which a cholangiocatheter was inserted.

Cholangiogram was performed, which did reveal multiple small filling defects, and it was unclear even with positional changes whether these were small stones or air bubbles. There was a mildly dilated common bile duct, but no obstruction in the duodenum, and there was normal hepatobiliary anatomy.

At this point, the cholangiocatheter was removed. The cystic duct and cystic artery were both ligated between clips, and the gallbladder was then removed from the gallbladder fossa by electrocautery. After ensuring adequate hemostasis in the liver bed, the right upper quadrant was copiously irrigated and suctioned dry, and the gallbladder was placed in an EndoCatch bag and removed through the umbilical port site without difficulty.

All ports were removed under direct visualization. The umbilical and epigastric fascial defects were reapproximated with 0 Vicryl suture, and all skin incisions were anesthetized with local anesthetic, including the subcuticular fascia. The patient tolerated the procedure well, awoke from anesthetic in stable condition, and was brought to recovery without incident.