DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute cholecystitis with cholelithiasis.
POSTOPERATIVE DIAGNOSIS: Acute necrotizing cholecystitis with cholelithiasis.
OPERATION PERFORMED:
1. Laparoscopy.
2. Open cholecystectomy with intraoperative cholangiogram.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was placed in the supine position on the operating table and general anesthesia was induced. Venodyne boots were in place. The abdomen was prepped with Betadine and draped in the usual manner. The abdomen was shaved and prepped with Betadine and draped in the usual manner. The patient was placed in Trendelenburg position. A 1 cm curved incision was made just below the umbilicus. The linea alba was grasped and a disposable Veress needle passed into the peritoneal cavity. After verifying its intraperitoneal position, carbon dioxide was insufflated through it to an intraperitoneal pressure of 15 mmHg. The laparoscope and camera were then introduced through a 10 mm cannula in this location and the interior of the abdomen examined. Gallbladder could not be seen as it was hidden by omentum, which went up to the liver. The visualized portions of the liver, stomach, small and large intestine appeared normal.
The patient was then placed in reverse Trendelenburg position and attention directed to the right upper quadrant. The 5 mm cannulae were introduced through the anterior axillary and midclavicular lines on the right side. A 10 mm cannula was introduced just to the right of the upper midline in the epigastrium. The omentum was bluntly dissected away from the gallbladder. The gallbladder was intensely hemorrhagic and distended. It was decompressed and thick white bile came out. After this, gallbladder was grasped and dissection was carefully carried out bluntly separating the omentum from it. The structures were quite vascular as they were inflamed and hemorrhagic. Dissection was slow as the adhesions were quite rigid. We attempted for quite a while to dissect the gallbladder free down to the hepatoduodenal ligament, but because of the intense vascularity and friability, we could not delineate the anatomical planes well.
It was felt at this point that we could not safely dissect down to the cystic artery, cystic duct, and common duct. It was therefore decided to switch to an open approach. A right subcostal skin incision was made by connecting the epigastric and midclavicular port sites. The incision was deepened to the subcutaneous tissue and the fascia. The rectus muscle was divided with electrocautery. The peritoneum was incised and access gained to the peritoneal cavity. The stomach, duodenum, and the hepatic flexure were packed away with moist laparotomy pads.
The gallbladder was grasped and dissection began. It was decided to dissect it in a retrograde fashion because of the intense inflammatory reaction near the hilum. The back wall of the gallbladder was necrotic and fell apart. It was carefully dissected free. When we came down to the hilum, there was a large fibriotic clot containing all these structures. It was difficult to determine which were the cystic artery and cystic duct. In order to improve visualization, the distal part of the gallbladder was excised. We then dissected three tubular structures, which appear to be cystic duct and then attempted to do a cystic duct cholangiogram using C-arm fluoroscopy. However, the catheter leaked as the tissues were very friable and thinned out. Accordingly, a cholangiogram was performed with direct injection of dye into the common duct. At this point, we noted there was also a small friable structure coming from the liver to the gallbladder, which had been divided while dissecting the gallbladder and cauterized, and there were a couple of drops of bile coming from here. In order to delineate the anatomy, half-strength dye was first injected into the common duct and C-arm fluoroscopy used. We saw a portion of the common duct.
Next, we made an injection using full spread dye directly into the common duct and this showed clearly full extent of the common duct as well as the intrahepatic radicles with both the right and left hepatic ducts being seen and appearing intact. It does identify that the structure next to the gallbladder was the cystic duct and that the common duct and rest of the ductal system was intact. The cystic duct was silver-clipped twice and then divided. The small ductal structure coming from the liver to the gallbladder was felt to be a duct of Luschka as the main ductal structures were intact. This was also silver clipped.
The entire right upper quadrant was irrigated with large amounts of saline. Hemostasis was ensured. A #10 Jackson-Pratt drain was placed in the Morison’s pouch and brought up to the anterior axillary port sites. It was anchored to the skin with a 2-0 silk suture. Closure was then begun. The posterior rectus sheath and peritoneum was closed with running suture of 0 Vicryl. The anterior rectus sheath was closed with a running suture with double looped 0 PDS. The subcutaneous tissue was closed with 2-0 Vicryl and the skin with 3-0 Vicryl placed in subcuticular fashion. Marcaine 0.25% was infiltrated into all layers prior to closure. Steri-Strips and a dry sterile dressing were applied. The umbilical port site had the fascia closed using 0 Vicryl with a J needle and the skin with 3-0 Vicryl subcuticular sutures. Blood loss during the procedure was about 200 mL. No transfusions were given. Tape and instrument counts were reported correct twice. The patient tolerated the procedure well and was transferred to the recovery room in good condition.
