Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 6

Description: Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Cholelithiasis; possible choledocholithiasis.

POSTOPERATIVE DIAGNOSIS: Cholelithiasis.

TITLE OF PROCEDURE: Laparoscopic cholecystectomy and intraoperative cholangiogram.

ANESTHESIA: General with endotracheal intubation.

PROCEDURE IN DETAIL: The patient was taken to the operating room and placed supine upon the operating room table. General anesthesia was administered with endotracheal intubation. The abdomen was prepped and draped in standard sterile surgical fashion. Marcaine was injected through the umbilicus. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus. I then placed a 5-mm port in the midline just subxiphoid, another 5-mm port in the midclavicular line just subcostal, and another 5-mm port in the mid-axillary line just subcostal. I grasped the fundus of the gallbladder and pulled it superiorly over the liver. The gallbladder was inflamed and did appear to have acute cholecystitis. There were some adhesions from the omentum, which were taken down. I grabbed the infundibulum of the gallbladder and pulled it inferolaterally, and thereby splayed out the cystic duct. The cystic duct was bluntly dissected. I put a clip distally against the gallbladder. I then cut a small hole in the cystic duct. I passed an Arrow catheter into the cystic duct and inflated the balloon. I injected dye under fluoroscopy, and I could feel the hepatic duct and the common bile duct. There were no stones in the common bile duct. The dye easily passed into the intestine. I then removed the Arrow catheter. I placed 2 clips proximally on the cystic duct, and I put an extra stitch through the duct at the very end with a Vicryl stitch to be sure that it was secured. I put 2 clips on the cystic artery, and 1 distally, and it was divided. I then took the gallbladder off the hepatic fossa using electrocautery. I placed it in an Endocatch bag and removed it through the umbilicus. I copiously irrigated out the abdomen. I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture. I closed the skin of all incisions with running Monocryl. Sponge, instrument and needle counts were correct at the end of the case. The patient tolerated the procedure well without any complications.

Keywords: surgery, choledocholithiasis, cholangiogram, co2 insufflation, umbilicus, common bile duct, bile duct, laparoscopic cholecystectomy, cystic duct, intraoperative, laparoscopic, cholecystectomy, cholelithiasis, endotracheal, gallbladder, cystic, duct,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples