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Laparoscopic Appendectomy Sample Report
Laparoscopic Appendectomy Sample Report
LAPAROSCOPIC APPENDECTOMY OPERATIVE EXAMPLE
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute purulentappendicitis.
OPERATION PERFORMED: Laparoscopicappendectomy.
ESTIMATED BLOOD LOSS: Minimal.
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient wasbrought into the operating room and laid supine on the operatingtable for laparoscopic appendectomy. Anesthesia was induced. Shewas intubated without difficulty. Sequential compression deviceswere placed on the lower extremities prior to induction ofanesthesia for DVT prophylaxis. A Foley catheter was placed at thebeginning of the procedure and removed at the end. Her abdomen wasprepped and draped in the normal sterile fashion usingChloraPrep.
Abdomen was entered through a supraumbilical incision, vertical,for 12 mm port site. The incision was made with a knife and carrieddown through the fascia under direct visualization, entering theperitoneum under direct visualization with an 11 blade. The localanesthetic used at all port sites was 0.25% Marcaine withepinephrine.
Once the umbilical port site was created, then the trocar wasinserted bluntly, and the abdomen was insufflated to 15 mmHgpressure with CO2 gas. Initially, a 0-degree, 10 mm Olympuslaparoscope was used to inspect her abdomen. The ascites, as noted,was observed and a circumferential view was taken of her abdomen.The adhesions above her liver were noted. Her gallbladder appearedsomewhat edematous but soft and thought to be probably in reactionto the surrounding abdominal inflammation.
The appendix was located in its more standard position in theright lower quadrant. It was covered by omentum and a portion ofthe distal ileum. The scope was then switched to a 45-degree, 10 mmscope and the two operating trocars were placed using 5 mm trocars,one suprapubic and one between the umbilicus and the pubic trocar.These were placed by creating an incision with a knife and then thetrocars were inserted under direct visualization.
First, the ascites was suctioned, and there was somefibrinopurulent material overlying her uterus and along the lateralborder of the liver on the right side, and all of this wassuctioned until clear and then swab cultures were taken of thisfluid by swabbing the tip of the suction instrument. Aerobic andanaerobic cultures were sent.
Once this was done, then the areas were irrigated with salineuntil the pus was cleared. Then, attention was placed towardsdissecting the appendix, which was easily dissected free of itsadhesions to the omentum bluntly and to the ileum, which had rolledover it bluntly.
There were some peritoneal attachments inferiorly and laterallyalong the cecum that required lysing and mobilization. This wasdone with electrocautery with a hook of the ConMed instrument andblunt dissection, so that the base of the appendix could beidentified as it is separated away from the cecum.
Once this was done, a Maryland dissector was used to dissect theneck of the appendix. Then, a blue load of the 45 GIA was used totransect the base of the appendix. This was done withoutdifficulty. The area was inspected. The staple line was noted to besecure, and there were some attachments medially to the distalileum that were lysed with blunt dissection and electrocautery,allowing the mesoappendix then to be able to pull away from thedistal ileum and pelvis so that then a white load of the GIA wasused to transect the mesoappendix. The staple line was inspectedand noted to be hemostatic.
The appendix was then placed within an EndoCatch bag afterswitching to a 5 mm, 45-degree scope. The EndoCatch bag was placedthrough the umbilicus and the appendix placed within it. The bagwas closed and left in the abdomen until the end of theprocedure.
Then, we proceeded to more thoroughly wash the abdomen now thatthe appendix was isolated. This was done with about total of 2000mL of saline, irrigating all four quadrants until all the irrigantfluid was clear. Again, the staple lines were inspected and notedto be secure. Then, a 19 Blake drain was cut to size and placedthrough the umbilical trocar and brought out through the mostinferior trocar sutured to the skin with 2-0 nylon. The tip of thedrain was placed at the pelvic brim with the shaft of the drainbetween the rectum and the uterus.
Once this was in place, then the trocars were removed. Theappendix was removed through the umbilicus within its bag withoutspillage. Closure of the fascia of the umbilicus was then done with0 Vicryl figure-of-eight sutures. The skin was reapproximated with4-0 Monocryl subcuticular sutures. The umbilicus was packed with 2x 2 gauze. Mastisol and Steri-Strips placed on the 5 mm port site.Gauze and Tegaderm were placed around the drain site. The Foleycatheter was removed.
The patient tolerated the laparoscopic appendectomy procedurewell. The patient was awoken, extubated, and transferred to therecovery room in stable condition.
CPT code for this procedure
