Laparoscopic Appendectomy Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
OPERATION PERFORMED: Laparoscopic appendectomy.
SURGEON: John Doe, MD
DESCRIPTION OF OPERATION: The patient was taken to the operating room and laid in supine position. He was endotracheally intubated and general anesthetic was given. His abdomen was prepped and draped in a sterile fashion. A Foley catheter was also placed prior to starting this procedure.
We began by infiltrating an area around his umbilicus with 0.25% Marcaine, dissected down through the skin and subcutaneous tissues, until identifying the umbilical stalk.
A small incision was made at the base of the stalk and the Veress needle was placed into the abdominal cavity. We insufflated the abdomen to a pressure of 15 with CO2.
We then replaced the Veress needle with a 12 mm port. We then placed the other ports under direct visualization, both 5 mm, one in the left lower quadrant and one in suprapubic region. There was a large amount of adhesions and free fluid within the abdominal cavity.
The right lower quadrant was very inflamed. The patient also appeared to have either an ileus or a partial small bowel obstruction. We were able to free up the cecum and identify the appendix, which was necrotic and very adherent to the surrounding tissues.
We were able to free up the appendix and actually did use an endo GIA stapler to staple across the base of the appendix, and the appendix came out in a piecemeal fashion. We did identify the fecaliths which were removed via ports.
Once we had completed with this, we irrigated out with copious amounts of saline in all four quadrants.
We then removed our ports under direct visualization and closed the umbilical port fascia with the single figure-of-eight stitch and closed skin in all three port sites with subcuticular stitches. Steri-Strips were applied.
The patient tolerated the procedure well, was awakened and extubated and taken to the PACU in stable condition. All sponge and needle counts were correct at the end of the case.
