Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Laparoscopic Cholecystectomy Operative Transcription Report

DESCRIPTION OF OPERATION:  The patient was brought into the surgical suite, placed on the operating table in the supine position. She was anesthetized and easily endotracheally intubated by Anesthesia. After adequate analgesia and anesthesia had been obtained, her abdomen was shaved, prepped and draped in the usual sterile manner using Betadine solution. She was on Zosyn preoperatively for antibiotic prophylaxis. She had an NG tube to low intermittent suction and a Foley catheter was already in place.

After abdomen was prepped, two towel clips were placed on either side of the superior umbilical fold and a stab incision was performed. A Veress needle was inserted into the abdomen with opening pressures of CO2 insufflation less than 5 mmHg. After an adequate pneumoperitoneum had been obtained, the Veress needle was removed and a 5 mm trocar was inserted. A 5 mm laparoscopic camera was inserted. The abdomen was surveyed, revealing a hugely distended gallbladder with obvious stones in the right upper quadrant beneath the liver edge. No other intraabdominal pathology noted. Positive pericholecystic fluid.

A 10 mm trocar was inserted in the epigastric region and two 5 mm trocars were inserted in line with the umbilicus in the midclavicular and anterior axillary lines under direct visualization of the laparoscopic camera. The gallbladder was elevated from the hepatic bed. Multiple adhesions in the transverse colon were removed. The cystic artery was identified, clipped three times proximally, once distally, and transected. The gallbladder was dissected down to the cystic duct where the cystic duct-common duct junction was visualized. The cystic duct was freed from the peritoneum and the surrounding tissues and the gallbladder was dissected posteriorly away from the liver edge, ensuring that no other ducts or tubes noted posterior to the cystic duct. The cystic duct was milked towards the gallbladder to remove any sludge or small stones within the cystic duct. The cystic duct was clipped three times proximally and once distally using extra long endoclips. Cystic duct was transected and the gallbladder was easily removed using Bovie electrocautery from the liver bed.

No intraoperative spillage noted, placed into an Endocatch and removed through the 10 mm trocar site, with some difficulty due to its multiple stones and a large state. Copious irrigation of the right upper quadrant and hepatic bed revealed no active bleeding or bile leaks. Copious irrigation of the abdomen was performed using 1 liter of normal saline. The 10 mm trocar site was approximated using 0-Vicryl and a figure-of-eight stitch using a Carter-Thomason closure device. Abdomen was deflated. All trocars were removed. Marcaine 0.5% was infiltrated in the incisions for postoperative analgesia.

A 4-0 Vicryl was used to approximate the skin edges. Benzoin, Steri-Strips, and a dry sterile dressing were applied. She was reversed from anesthesia, extubated on the operating table, and transferred to the postanesthesia recovery in stable condition. All instrument, needle, and sponge counts were corrected x3 at closure. The patient tolerated the procedure well.

More Laparoscopic Cholecystectomy Sample Reports