Lap Chole Dictation

Laparoscopic Cholecystectomy
This is Dr. _______ dictating an operative note on pt ____, MRN____ copies to Dr.____ (MRP, to the chart and to the pt's
family doctor)
DATE OF PROCEDURE:
PROCEDURE
1) Laparoscopic cholecystectomy
2) intra-operative cholangiogram
PREOP DX: (symptomatic cholelithiasis/gallstone pancreatitis

POSTOP DX: same
SURGEON:
ASSISTANT:
ANESTHETIST:
ANESTHETIC: General anesthetic
SUMMARY OF EVENTS & FINDINGS:

1) No intra-operative complications
2) Specimen to pathology: gallbladder
3) Drains
4) Disposition – PACU/ICU
CLINICAL NOTE:
Mr/Mrs ___ is a ____-year old man/woman who was evaluated in Dr. _______ clinic with symptoms of biliary colic.
There was sonographic evidence of gallstones.
Surgery was indicated and recommended. The risks, benefits, alternative and rationale of surgery explained as
documented in Dr. ______ clinic note, including the risk of not operating. Informed consent was obtained in clinic by Dr.
________ for a laparoscopic possible open cholecystectomy which we performed today.
OPERATIVE NOTE:
The patient was brought to the operating room where a surgical safety checklist was performed. Preoperatively, ___
grams of IV Ancef/Vancomycin was administered. General anaesthesia was induced.
A foley catheter (was/was not) inserted as (the patient was able to void immediately prior to the operation). Arms
were/were not tucked. In supine position, the abdomen was prepped and draped in a sterile fashion.
A supra/infra umbilical midline incision was made and carried down to the fascia which was divided exposing the
peritoneal cavity. ‘0’ vicryl sutures were used to place two stay sutures into the midline fascia. An open/closed technique
was used to enter the peritoneal cavity with a Hassan/Verres needle and used to establish our pneumoperitoneum. The
laparoscope was inserted into the abdomen under direct vision.
Subsequently the following ports were inserted under direct visualization (along with local anesthetic) in the typical
fashion: a 10/12 mm epigastric port and two 5 mm ports along the right costal margin. The peritoneal cavity was
inspected and (no abnormalities/the following abnormalities were found).
- Additional trocars were/were not placed because __________.
The patient was placed in reverse Trendelenburg position with the right side up.
Omental attachments to the gallbladder were gently swept away until an atraumatic grasper could be used to retract the
fundus of the gallbladder superiorly over the dome of the liver.
- Filmy adhesions between the gallbladder and omentum/duodenum were also lysed sharply.
The infundibulum was identified and subsequently retracted laterally towards the right lower quadrant using another
grasper. This maneuver exposed Calot’s triangle. The peritoneum overlying the gallbladder infundibulum was incised
with electrocautery anteriorly. Then the posterior peritoneum was dissected. The triangle was dissected to expose:
1) the cystic duct LN
2) cystic artery
3) cystic plate
4) cystic duct
Once these structures were carefully identified, the cystic artery was divided first. Then further dissection of the triangle
was completed. Once it was determined that the only structure remaining, entering the gall bladder was the cystic duct, it
was doubly clipped and divided.
(If Cholangiogram: A clip was placed on the cystic duct close to the neck of the gallbladder. A nick was made in the
cystic duct and a cholangiogram catheter threaded. A cholangiogram was obtained and showed good flow of bile into the
duodenum, an intact biliary tree, and absence of any filling defects/other).
The electrocautery was then used to separate the peritoneal attachments between the gallbladder and its bed in the liver.
The gallbladder fossa and cystic artery were inspected to ensure no bleeding. Hemostasis was achieved with
electrocautery. There was/was not leakage of bile from the cystic duct stump.
The gallbladder, once freed, [was placed in an endoscopic retrieval bag and] easily removed from the abdomen through
the epigastric port. The specimen was sent to pathology.
The fascia at the supra-umbilical and epigastric ports were re-approximated using the 1-0 or 0’ (vicryl/biosyn) sutures in a
figure-of-eight fashion. All incisions were closed using 4-0 (vicryl/biosyn) sutures in an (interrupted/continuous) sub-
cuticular fashion. The operative field was cleaned and dried. Steri-strips/dressings were applied.
There were no intraoperative complications and estimated blood loss was ____ cc. All instrument and sponge counts
were correct. A surgical de-briefing was performed. The patient was extubated and transferred to the PACU in stable
condition.
Additional details should be added as necessary related to:

- difficulty in the dissection of the triangle
- bleeding from liver
- bleeding from posterior cystic artery
- spillage of stones
- retrieval of the specimen from the abdomen
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NOTE: Should only be used for routine operations. For more challenging operations, a modified template may be
needed.

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Lap Chole Dictation

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Laparoscopic Cholecystectomy

PREOP DX: (symptomatic cholelithiasis/gallstone pancreatitis

SUMMARY OF EVENTS & FINDINGS:

Additional details should be added as necessary related to:

------------------------------------------------------- End of Dictation --------------------------------------------------------

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