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Laparoscopic Cholecystectomy Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Cholecystitis with cholelithiasis.

POSTOPERATIVE DIAGNOSIS:
Cholecystitis with cholelithiasis.

OPERATION PERFORMED:
Laparoscopic cholecystectomy with operative cholangiogram.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:
General endotracheal anesthesia.

ANESTHESIOLOGIST:  John Doe Jr., MD

ESTIMATED BLOOD LOSS:
Less than 100 mL.

DRAINS:
No drains were used.

DISPOSITION:
To the recovery room.

DESCRIPTION OF OPERATION:
Under general endotracheal anesthesia, the patient was put in the supine position.  The abdomen was prepped with Betadine and draped in a standard fashion.  A subumbilical incision was made.  The incision was deepened through the fascia.  The peritoneal cavity was entered.  Digital palpation was done.  Stay sutures were placed in the fascia.

A blunt cannula was inserted into the peritoneal cavity under direct vision and anchored with stay sutures.  Pneumoperitoneum was produced and maintained at 14 mmHg.  The patient was put in reverse Trendelenburg position.  A #10 Surgiport was introduced in the epigastric region.  Under direct vision, two 5 mm ports, one in midclavicular and another in anterior clavicular line, were placed.  Through the 5 mm ports, grabbers were introduced to grab the fundus and Hartmann pouch.

Through the epigastric Surgiport, a microdissector was introduced with blunt and sharp dissection.  The omentum over the gallbladder was mobilized and released.  Then, the peritoneum over the porta hepatis was gently teased.  The cystic duct and artery were identified.  The whole triangle was visualized.  The cystic duct was clipped proximally, and a cystic duct cholangiogram was done with fluoroscopy, which shows the dye going freely into the duodenum and into the proximal duct.  No filling defects were seen.

After the cholangiogram was done, the catheter was removed, and the cystic duct was clipped distally and divided.  Then, the cystic artery was further mobilized and was clipped proximally, distally, and divided.  Then, the gallbladder was separated all the way from the neck to the fundus with Bovie, and hemostasis was established in the gallbladder bed with electrocoagulation.  After the gallbladder was completely separated, the patient was put in supine position.  The camera was introduced through the epigastric Surgiport and a grabber was introduced through the subumbilical port, and the gallbladder was removed containing multiple small stones.

Then, the subumbilical wound was approximated with 0 Vicryl.  The subcutaneous and subhepatic areas were irrigated with saline and aspirated, and after making sure there is good hemostasis, all the Surgiports were removed and the pneumoperitoneum was reversed, and the skin wounds were approximated with 4-0 Vicryl in a subcuticular fashion.  Marcaine 0.25% with epinephrine was infiltrated in the wounds.  A sterile dressing was applied.  The patient tolerated the procedure well and was brought to the recovery room in stable condition.