Open chole

PROCEDURE IN DETAIL:
The patient was brought in the operating room and placed on the operating table
in supine position. The patient underwent general endotracheal anesthesia and
was prepped and draped in usual sterile manner. Then using a #15 blade, a
curvilinear skin incision was made. The incision was carried down through the
skin through the subcutaneous tissue and using electrocautery, hemostasis was
obtained. The incision was extended down to the fascia, the fascia was opened,
the abdominal cavity was entered under direct visualization. Two stay sutures
were placed on either side of the fascia. The Hasson trocar was placed into the
abdominal cavity. Under direct visualization pneumoperitoneum was created with
an opening pressure of 0 to a pressure of 15 with good 4-quadrant tympany at all
times. The scope was placed through the Hasson trocar and found to be in good
position. A 12-mm trocar was then placed in the epigastric region under direct
visualization and a 5-mm trocar was placed in the right upper quadrant along the
anterior axillary line, also under direct visualization. Upon exploration of

PATIENT NAME: GRAVES,BRIAN

ACCOUNT #: V034218398

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the abdomen, the patient was found to have the omentum stuck up over the liver.
The omentum was taken down off of the liver edge. A portion of the gallbladder
could be visualized laterally and there was omental fat markedly adhered to the
edge of the liver encasing the gallbladder around the entire area. Attempt was
made to separate the omentum and the fat off of the area of where the

gallbladder was. Due to the amount of fat in the area, it was difficult to
determine whether there was any bowel stuck to the gallbladder as well. At this
point, it was felt to abort the laparoscopic method since visualization was not
possible and the dissection was not deemed to be safe. At this point, the
laparoscopic method was aborted and the patient was _____. A right subcostal
transverse skin incision was made using a #10 blade in between the 2 trocars,
the incision was carried down through the skin to the subcutaneous tissue and
using electrocautery, hemostasis was obtained. The incision was extended down
through the subcutaneous tissues to the fascia. The fascia was opened. The
rectus muscle was transected using electrocautery. The abdominal cavity was
entered, the incision was extended medially and laterally using electrocautery.
At this point, the omental fat was then bluntly dissected off of the liver edge
as well as using electrocautery until the gallbladder could be identified.
There were adhesions and fat stuck to the body of the gallbladder and these were
taken down using electrocautery as well as blunt dissection. The gallbladder
was then elevated up self-retaining retractors were placed. The dissection of
the gallbladder was started superiorly and carried down towards the neck of the
gallbladder. The peritoneum of the gallbladder was then opened and the
gallbladder was separated off of the liver edge using electrocautery as well as
blunt dissection. The dissection was carried laterally using electrocautery
until the neck of the gallbladder was identified, it was also carried medially
using blunt dissection as well as using electrocautery. The cystic artery was
first identified, it was transected in between clips. The gallbladder was then
completely separated off of the liver edge until the gallbladder was left
hanging off of the cystic duct. Once the gallbladder was completely separated
off of the liver and only left on the cystic duct, the cystic duct was then

doubly clipped, a right angle clamp was placed at the neck of the gallbladder
and the gallbladder was transected off and sent to pathology. The edge of the
cystic duct stump was then oversewn using a figure-of-eight interrupted 3-0
Prolene sutures. The abdominal cavity was then irrigated with copious amounts
of saline. Hemostasis was obtained using electrocautery. The umbilical fascial
incision was then closed using figure-of-eight 0 Vicryl sutures. The posterior
fascia was then closed using a running 0 Vicryl stitch and then the anterior
fascia of the right subcostal incision was closed using a running #1 PDS suture.
The subcutaneous tissue was irrigated with saline. Hemostasis was obtained
using electrocautery. The wounds were stapled closed. All sponge and needle
counts were correct. Sterile dressings were applied. The patient tolerated
procedure well and was taken to recovery room in stable condition.