Here is an example of a surgery chart for a laparoscopic cholecystectomy:
Preoperative Diagnosis: Cholelithiasis
Postoperative Diagnosis: Cholelithiasis
Procedure: Laparoscopic Cholecystectomy
Anesthesia: General
Indications: The patient is a 45-year-old female with a history of recurrent biliary colic and gallstones. An ultrasound revealed multiple stones in the gallbladder.
Description of Procedure: The patient was brought to the operating room and placed under general anesthesia. A small incision was made in the umbilicus, and a laparoscope was inserted to visualize the abdomen. Additional small incisions were made in the right upper quadrant and epigastrium to accommodate the insertion of the necessary instruments.
The cystic artery and duct were identified and clipped and cut, and the gallbladder was dissected free from the liver bed using electrocautery. The gallbladder was removed through the umbilical incision. The cystic duct and artery were confirmed to be securely clipped and cut. Hemostasis was obtained, and the incisions were closed with absorbable sutures.
The patient tolerated the procedure well, and there were no intraoperative complications.
Estimated Blood Loss: Minimal
Specimens Removed: Gallbladder
Postoperative Course: The patient was transferred to the post-anesthesia care unit and monitored closely for several hours. She was then transferred to the surgical floor, where she was given pain medication as needed and encouraged to ambulate. She was discharged home on postoperative day one with instructions to continue pain medication as needed and to follow up with her surgeon in two weeks.
Follow-up: The patient returned to the clinic two weeks after surgery for a follow-up visit. She reported minimal pain and no complications. Her incisions appeared to be healing well, and her pathology report confirmed the presence of multiple gallstones. She was instructed to follow a low-fat diet and to avoid heavy lifting for several weeks. She was scheduled for a follow-up ultrasound in six months to ensure that no residual stones were present.