Surgery Report

As I mentioned, I had emergency surgery in early May. The following is the surgery report, verbatim. I am truly amazed by the sophistication of modern medicine. This is extremely high-tech stuff, folks! We are genuinely lucky to have access to such sophisticated medical care and competent doctors. Check this out: (and no, you're not misreading this; they really did stick a camera inside me!)

Operation/Procedure Report
Steve E. Lester, MD-Kaiser
Adm Date: 05/02/2007
Dis Date: 05/05/2007

Date of Surgery: 05/03/07

Preoperative Diagnosis: Acute cholecystitis

Postoperative Diagnosis: Acute cholecystitis

Operation(s): Laparoscopic cholecystectomy

Surgeon(s): Steven Lester, MD

Assistants:
1. Eugene Chang, MD
2. Monica Arora, MS3

Anesthesia: General endotrachael anesthesia

INDICATIONS: The patient is a 38-year old woman who presented to the Emergency Room with right upper quadrant abdominal pain. She had a white blood cell count of 10,000. An ultrasound of the right upper quadrant demonstrated stones within the gallbladder with pericholecystic fluid and gallbladder wall thickening and a common bile duct of 7-10mm. Liver function tests demonstrated a total bilirubin of 1.0, AST and ALT of 34 and 31 respectively and an alkaline phosphatase of 51. Her lactase level was 17. Based on these findings, she was felt to have acute cholecystitis. A PARQ conference was held with the patient and she agreed to a laparoscopic cholecystectomy. She was brought to the operating room for this purpose.

FINDINGS: Very inflamed, edematous gallbladder filled with multiple large, hard stones. Some stones came out of the gallbladder when the gallbladder was entered and each stone was scooped up and removed as it came out of the gallbladder.

PROCEDURE IN DETAIL: The patient was brought to the operating room. General anesthesia was established and the patient’s abdomen was prepped and draped in standard sterile surgical fashion.

A vertical incision was made inferior to the umbilicus in order to place our camera port. This was performed after infiltration with local anesthetic. Blunt dissection was used to carry the incision down through the fascia and a Veress needle was inserted. A drop test was performed, confirming our position inside the peritoneal cavity. A carbon dioxide pneumoperitoneum 11-mm trocar was placed through the umbilical site and a laparoscope was inserted. The gallbladder was inspected and found to be very edematous, indurated and inflamed. We decided to proceed with the laparoscopic cholecystectomy.

Attention was turned to the subxiphoid site where an 11-mm transverse incision was made after infiltration with local anesthetic. Using the Step System, an 11-mm trocar was placed. Similarly, two 5-mm ports were placed in the right abdomen. Again, local anesthetic was used to infiltrate these sites prior to placements of the ports.

The gallbladder was then decompressed using a needle to suction out the bile. The gallbladder was then grasped with graspers and retracted cephalad and laterally. There was some fat adherent to the surface of the gallbladder and this was stripped off using Maryland dissectors. The peritoneal membrane overlapping the base of the gallbladder and the cystic duct was stripped off. Due to the amount of inflammation that we encountered, a very meticulous dissection of the cystic duct and cystic artery was then carried out in order to identify them. This was performed by the triangle Calot and identifying the node of Calot. The attachments to the node were electrocauterized and the node was removed. Further dissection was used to demonstrate a cystic duct that branched and then entered the gallbladder after it branched. It also gave some smaller branches to the cystic duct.

Additional dissection was carried out in the triangle of Calot to remove the scar tissue present in the area, demonstrating a critical view of safety. The branches from the cystic artery to the cystic duct were clipped and divided. The cystic duct was then clipped with one clip on the gallbladder sude and two clips on the opposite side and divided. Each branch of the cystic artery leading into the cystic duct was then clipped and divided. The gallbladder was then retracted away from the liver and was dissected off using electrocautery. In this process, the gallbladder was entered, revealing a large number of stones within. The stones which escaped were noted immediately and were scooped up with a stone scoop and removed. Once the gallbladder was fully dissected off of the liver, it was placed in an EndoCatch bag and removed through the umbilical port with visualization through the subxiphoid port. This was facilitated by extending the fascial and skin incisions vertically downward. The gallbladder was handed off the field as a specimen.

The trocar was reinserted and the gallbladder was inspected. No active bleeding was seen. The clips on the cystic duct and cystic artery were inspected and found to be intact. This area was irrigated and the irrigant was suctioned out through a site lateral to the liver. The irrigant ran clear. A fluted Jackson-Pratt drain was placed through one of the right-sided incisions down into the gallbladder fossa and on the underside of the liver. It was sutured into place using a nylon suture. The camera was swiveled around in order to provide a 360-degree view of the abdomen which revealed no other pathologic abnormalities. The trocars were then removed under vision through the laparoscope and no bleeding was seen. This final trocar was removed as the layers of the abdominal wall were visualized. No bleeding was seen at this point either. The pneumoperitoneum was allowed to escape. An umbilical site was closed with 0 Vicryl to the skin in a subcuticular fashion. The incisions were dressed. The drapes were removed. The patient was allowed to awaken, having tolerated the procedure well.

SPECIMENS: Gallbladder

ESTIMATED BLOOD LOSS: 75 mL

COMPLICATIONS: None interoperatively