DESCRIPTION OF OPERATION: The patient was taken back to the operating suite and placed under general inhalation anesthesia. The patient was sterilely prepped and draped in the usual fashion. Foley catheters were used to decompress the bladder. Oral gastric tube was used to decompress the stomach. Then, 0.5% Marcaine with epinephrine was infiltrated under the skin as a local anesthetic. A vertical subumbilical incision was made with a scalpel. Dissection progressed down to the umbilical fascia with hemostats. The fascia was grasped with hemostats and the fascia was incised. The abdomen was entered bluntly, anchoring suture of 0-Vicryl was placed. Hasson trocar was placed in the abdomen. Abdomen was insufflated with CO2 gas. Upon initial examination of the abdomen, findings were noted as above. There was a large amount of adhesions. We planned to place a right lateral port, 5 mm, first and move the camera to the area and take down all the adhesions before we can proceed further because the adhesions were in the way of where we were going to put our port sites. Once we are able to get the adhesions taken down, we then placed another two 5 mm ports in the right upper quadrant, in subxiphoid area. We uncovered the omentum off of the gallbladder with some difficulty. Everything was very inflamed and the omentum bled readily. Once we were able to get that off, we were able to grab some purchase onto the gallbladder and dissect down the cholecystoduodenal ligament. The cholecystoduodenal ligament was taken down with blunt dissection. The cystic duct was isolated with blunt dissection, clipped twice proximally, once distally and ligated. The cystic artery was isolated with blunt dissection, clipped twice proximally, once distally and ligated. The gallbladder was dissected free from the liver bed using argon beam coagulator. It was placed in Endopouch and brought out through an umbilical incision, which had to be enlarged to twice its normal size to accommodate for the size of the distended gallbladder and its stones. While we were dissecting the gallbladder free, the gallbladder was found to be very friable and pieces of it would tear off just from holding with graspers, or the graspers would puncture the gallbladder. Once this was seen, purulent material was seen coming out the gallbladder. After the gallbladder was removed, the area was irrigated and suctioned back until clear, any bleeding points stopped with argon beam coagulator. There was good hemostasis. No evidence of any bowel injuries. The abdomen was desufflated. Ports were removed. Laparoscope was removed. The umbilical fascia was approximated with a figure-of-eight suture of 0-Vicryl and the skin was approximated with 4-0 Vicryl in a subcuticular fashion. Because of the oozing, a 10 mm flat Jackson-Pratt drain was placed in the abdomen at the gallbladder fossa and brought out through the lateral port site. It was sewn in with 3-0 nylon and hooked to bulb suction. The patient tolerated the procedure well and taken to the postanesthesia recovery in stable condition. All packs, instruments, and needles were accounted for.
