PATIENT INFORMATION:
Name: John Smith
DOB: 01/01/1970
Sex: Male
Medical Record Number: 123456789
DATE OF SURGERY: 04/08/2023
SURGEON: Dr. Jane Doe
PROCEDURE: Laparoscopic Appendectomy
INDICATION: Acute appendicitis
PROCEDURE DESCRIPTION:
Under general anesthesia, the patient was placed in a supine position and a Veress needle was used to establish pneumoperitoneum. Three trocars were inserted into the abdomen for laparoscopic visualization and instrumentation. The appendix was identified and found to be inflamed and enlarged. The mesoappendix was divided and the appendix was dissected free from the surrounding tissue. The base of the appendix was ligated with endoloops and the appendix was then removed from the abdomen through one of the trocar sites. Hemostasis was achieved and the trocar sites were closed. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
FINDINGS:
Inflamed and enlarged appendix consistent with acute appendicitis.
COMPLICATIONS:
None.
PATHOLOGY:
The appendix measured 7 cm in length and 1.5 cm in diameter. Histologic examination showed acute inflammation consistent with acute appendicitis.
DIAGNOSIS:
Acute appendicitis
CPT CODE:
44970 – Laparoscopic Appendectomy
ICD-10 CODE:
K35.1 – Acute appendicitis with generalized peritonitis
FOLLOW-UP:
The patient was discharged home on postoperative day 1 with instructions to rest and avoid strenuous activity for 1-2 weeks. The patient was advised to return for a follow-up appointment in 2 weeks for evaluation of the incision sites and to discuss pathology results.