Laparoscopic Cholecystectomy
After informed consent was obtained, the patient was taken to the Operating Suite and placed supine on the operating table. General endotracheal anesthesia was induced. Preoperative antibiotics were administered. The patient's abdomen was prepped and draped in the usual sterile surgical fashion. A time-out was performed with all team members present.
A 5 mm transverse supraumbilical incision was made and a Veress needle was inserted. The abdomen was insufflated with carbon dioxide gas to a pressure of 15 mmHg. The Veress needle was withdrawn and a 5 mm port was inserted and a laparoscope was then placed. A general survey of the abdomen was conducted and no injuries from Veress needle or trocar insertion were noted. Inspection of the right upper quadrant showed an acutely inflamed and distended gallbladder. Under direct vision, additional ports were placed in the following locations: A 10 mm subxiphoid port and two right subcostal lateral ports. No injury from trocar placement was noted.
Using two blunt graspers, the gallbladder fundus was retracted cephalad and the infundibulum retracted laterally. The cystic duct was then circumferentially dissected bluntly. After appropriate dissection two surgical clips were applied to the proximal portion of the duct and one clip was applied distally. The cystic duct was then divided sharply using laparoscopic scissors. Dissection then continued until the cystic artery was identified. Blunt dissection was used to circumferentially dissect the cystic artery. Two surgical clips were placed proximally and one clip was placed distally on the cystic artery. The artery was then divided sharply using laparoscopic scissors.
The gallbladder was dissected off of the liver using bovie hook electrocautery. Once the gallbladder was dissected off, it was placed in an endoscopic retrieval bag and removed from the abdominal cavity as specimen via the 10 mm port. After careful irrigation, there appeared to be good hemostasis at the gall bladder fossa and cystic artery stump.
The ports were removed under direct vision and no bleeding was noted. The abdomen was allowed to collapse. The fascia of the 10 mm port was closed with an 0 Vicryl stitch and simple interrupted fashion and the skin of all ports was closed with a 4-0 Monocryl in a subcuticular fashion. The wounds were cleaned and dressed with Steri-Strips.
Patient tolerated the procedure well and there were no complications. All needle, lap and sponge counts were reported as correct. Patient was extubated in the Operating Room and taken to the recovery room in stable surgical condition.


OPERATIVE Dictations
DD Surgical LLC
Always perform a time out with the entire team present!
There is always time for briefing and debriefing !

This example utilizes the veress needle and 4 ports. Please note there will be variations from surgeon to surgeon. Sone surgeons place the 10 mm port either at the umbilucus of the sub-xiphoid area. The manner in which the gallbladder is dissected from the liver bed also varies ( cautery vs ultrasonic scissors, dome down, etc.) Your role as the junior resident is to pay close attention to the steps of the procedure. If you have any doubts of portions of the procedure either during or after you should talk to your attending.


Note:
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