mt sample report: general surgery

INTRAOPERATIVE FINDINGS: The patient had severe acute cholecystitis as noted. The gallbladder was extremely large and inflamed. However, a laparoscopic cholecystectomy was able to be accomplished as will be described below.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was brought to the operating room and was placed in the supine position where general endotracheal anesthesia was induced. The patient's abdomen was prepped with Betadine and draped in the usual sterile fashion. A supraumbilical approach was chosen, because the patient had a previous hysterectomy and the incision extended all the way up above the umbilicus.

The incision was carried through the subcutaneous tissue and then the fascia was identified. Traction sutures of 0-Vicryl were placed. A longitudinal fascial incision was made and the peritoneum was entered bluntly. We were free of adhesions at this point. The Hasson cannula was inserted and the peritoneal cavity insufflated to a pressure of 15 mmHg.

Utilizing the 0-degree laparoscope with the patient in the reverse Trendelenburg position, an additional 11-mm port was inserted into the epigastrium just to the right of the midline. Then 5-mm ports were inserted in the midclavicular and anterior axillary lines, all under direct vision.

The gallbladder was identified and there were a few adhesions. It was extremely indurated and inflamed, and firm. It could not be grasped. For this reason, an 18-gauge angiocath was placed through the abdominal wall. The gallbladder was held up and this was placed in the gallbladder on the medial aspect next to the fundus. However, the bile was so thick that it could not be aspirated. This was removed and there was some spillage of bile from the needle hole.

A 12-gauge angiocath needle was then brought into the field and this was also placed in the gallbladder, but again, I could aspirate only about 2-3 cc of fluid.

Again, there was some drainage through the hole. The gallbladder was pushed with the forceps and I suctioned a large amount of the bile. A culture was done of the bile. Following this, we were able to grasp the fundus of the gallbladder with Davol forceps. However, the size of the gallbladder made exposure somewhat difficult. I was able to grasp the infundibulum and there was some very edematous infundibular fat which was dissected away and eventually, I was able to identify a structure which I initially thought was the cystic artery but it was somewhat small, but after further inspecting it, I determined it was the cystic duct. It was filling up into the gallbladder. The common duct could be identified. I did not attempt to completely dissect out the cystic duct and common duct junction as we were staying right on the gallbladder.

The duct was singly clipped adjacent to the gallbladder, doubly clipped proximally and divided. Dissection was continued. Some of the veil of cirrhosis was dissected away using the hook cautery setting at 20 watts. With this done, I could appreciate what appeared to be a vascular pedicle. When this was isolated, there appeared to be one branch coursing up onto the gallbladder and this was an anterior artery. This was doubly clipped proximally and singly clipped adjacent to the gallbladder and divided. There was some arterial bleeding at the proximal aspect that did not appear to be completely clipped and an additional clip was placed which controlled this. This was distal to the first two clips.

Again, there appeared to be an anterior and a posterior cystic artery in this area. The dissection was continued using the hook cautery. Another vascular structure was identified and this was able to be clipped with some bleeding.

Dissection at this point was very laborious as the gallbladder was very stuck and the serosa was very thickened. Eventually, with continued dissection, it was able to be removed. One small laceration was made on the right side of the liver using the Davol forceps during this dissection. This appeared to almost stop bleeding. After the gallbladder was removed, the liver bed was inspected and the liver bed was otherwise noted to be hemostatic. The right upper quadrant was irrigated copiously with normal saline solution. A total of two liters of irrigation was used during the procedure.

A small piece of Surgicel was then placed in the field and then placed in the small area of the laceration on the right side of the liver bed. This resulted in good hemostasis.

The laparoscope was then placed through the epigastric port site and endobag through the infraumbilical port site. The gallbladder was placed in the bag and was brought up into the incision, but the incision was not adequate to remove the gallbladder, so it had to be extended superiorly and inferiorly. Eventually, we were able to remove the gallbladder. It contained two very large stones.

The Hasson cannula was reinserted and the remaining port sites inspected and removed under direct vision.

The fascia on the supraumbilical wound was then closed with a total of five interrupted 0-Vicryl sutures. Subcutaneous tissue was irrigated and closed with 4-0 Vicryl sutures and the skin was closed with running 4-0 Vicryl subcuticular suture. The epigastric port site was closed with interrupted buried 4-0 Vicryl sutures and the remaining incisions were closed with Steri-Strips.

All sponge, needle, and instrument counts were reported as correct at the end of the procedure. The patient tolerated the procedure well and left the operating room for the recovery room in stable and satisfactory condition.

Herniorrhaphy Sample Report

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VENTRAL HERNIA REPAIR WITH MESH

PREOPERATIVE DIAGNOSIS: Ventral hernia.

POSTOPERATIVE DIAGNOSIS: Ventral hernia.

TITLE OF PROCEDURE: Ventral hernia repair with mesh reinforcement.

SURGEON: Michael Michaels, M.D.

ANESTHESIA GIVEN: General.

INDICATIONS FOR PROCEDURE: The patient is a 42-year-old gentleman who noticed a painful bulging which developed while doing strenuous activity at work, which has progressively worsened. On examination, he has a ventral hernia and he now presents for repair.

DESCRIPTION OF OPERATIVE PROCEDURE: The patient was brought to the operating room and following adequate general anesthesia, the abdomen was prepped and draped in the usual sterile fashion.

A 5-cm skin incision above the umbilicus was made and carried down to the level of the fascia where the hernia defect was identified. The defect was approximately 3-cm in size and contained incarcerated omentum. We were able to dissect to the base of the hernia, slightly enlarge the defect, and then reduce the omentum intraabdominally. Prolene mesh was then fashioned to an appropriate size. This was placed in inlay fashion using interrupted 2-0 Prolene suture to fixate this beneath the fascia. The piece that was used was significantly larger than the defect in an attempt to reinforce the fascia above and below, which was a bit thin. Once this had been performed, all sutures were tied, giving us a nicely placed mesh on the undersurface of the fascia. The fascial defect itself, was able to be approximated with 2-0 Vicryl sutures overlying the mesh repair. The wound was irrigated.

The subcutaneous tissues were closed with Vicryl and the skin was closed with Monocryl. A pressure dressing was applied. The patient tolerated the procedure well. There were no complications. Blood loss was minimal.

Operative Report - Sample Laparoscopic Appendectomy

PREOPERATIVE DIAGNOSIS: Right lower quadrant pain.

POSTOPERATIVE DIAGNOSIS: Right lower quadrant pain.

TITLE OF OPERATION: Laparoscopic appendectomy.

SURGEON: Michael Jones, M.D.

FIRST ASSISTANT: John Doe, Surgical Assistant.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Less than 30 cc.

INDICATIONS FOR PROCEDURE: The patient is a 20-year-old female who had persistent right lower quadrant pain despite a negative workup. Because of the persistent symptoms, the patient was taken to the operating room for a diagnostic laparoscopy.

DESCRIPTION OF OPERATIVE PROCEDURE: After informed consent was obtained, the patient was taken to the operating room and was placed in the supine position. General endotracheal anesthesia was performed. The abdomen was prepped and draped in the usual sterile fashion.

A small transverse incision was made below the umbilicus and a Veress needle was used to enter the peritoneal cavity which was insufflated with CO2 up to 15 mmHg of pressure. Next, a #12 trocar was placed. The camera was then placed through this trocar which confirmed its placement and there was no evidence of bowel injury. Next, under direct visualization, two more #5 trocars were placed, one in the suprapubic region and the other one into the left lower quadrant. The peritoneal cavity was then thoroughly examined. The right colon and terminal ileum were normal. The uterus and bilateral ovaries were normal. No other abnormality was found. The appendix was then examined. The appendix was found to be very long and retrocecal. The appendix, especially the tip, was injected and mildly edematous. It was felt at this time that the patient's right lower quadrant pain was most likely caused by this subacute type appendicitis. Next, the base of the appendix was then divided with the endo-GIA stapler. The mesoappendix was then serially divided with the endovascular stapler. The appendix was then gradually mobilized from its retrocecal position. After the mesoappendix was completely divided, the appendix was then free and then placed in the bag which was then removed.

The right lower quadrant was then irrigated and there was no evidence of bleeding. The infraumbilical fascial incision was then closed with 0-Ethibond suture using a needle passer. All trocars were removed under direct visualization. Then 0.5% Marcaine without epinephrine was injected. All skin incisions were closed using 4-0 Vicryl in a subcuticular fashion.

All counts were correct and the patient tolerated the procedure well. There were no immediate complications.

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