OPERATIVE REPORT
Patient Name: John Doe
Procedure: Laparoscopic Cholecystectomy
Date of Procedure: April 5, 2023
Surgeon: Dr. Jane Smith
INDICATIONS: The patient presented with symptoms of cholelithiasis, including recurrent right upper quadrant pain, nausea, and vomiting. The diagnosis was confirmed by ultrasound, which demonstrated multiple gallstones.
PROCEDURE: The patient was brought to the operating room and placed in a supine position under general anesthesia. A Foley catheter was inserted, and the patient was prepped and draped in a sterile fashion. A Veress needle was inserted into the peritoneal cavity, and pneumoperitoneum was established. Four trocars were then placed, including a 10-mm trocar in the umbilical region, a 5-mm trocar in the epigastric region, and two 5-mm trocars in the right upper quadrant.
Upon exploration of the peritoneal cavity, the gallbladder was identified and found to be distended with multiple stones. The cystic duct and artery were identified and dissected, and a clip was placed across the cystic duct. The gallbladder was then dissected from its bed using electrocautery and removed through the umbilical port site. Hemostasis was achieved, and the trocar sites were closed with absorbable sutures. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
FINDINGS: The gallbladder was distended with multiple stones, consistent with the preoperative diagnosis of cholelithiasis. The cystic duct and artery were identified and clipped, and the gallbladder was removed without complication.
IMPRESSION: Laparoscopic cholecystectomy was performed without complication for cholelithiasis.
COMPLICATIONS: None.
DISPOSITION: The patient was transferred to the recovery room in stable condition and was discharged home the following day.
OPERATIVE TIME: 1 hour.
CPT CODE: 47562 – Laparoscopic cholecystectomy.
Regenerate response