Você está na página 1de 2

Laparoscopic Appendectomy

This is Dr. _______ dictating an operative note on patient ____, MRN____ copies to Dr.____ (MRP, to the
chart and to the patient's family doctor)
1) Laparoscopic appendectomy
(2) +/- Drainage of intra-abdominal
PREOP DX: Acute appendicitis
POSTOP DX: Acute appendicitis (simple/perforated +/- abscess pelvic, sub-phrenic/diffuse peritonitis)
ANESTHETIC: General anesthetic
1) (Non-perforated appendix; Perforated appendix; Intra-abdominal abscess)
2) No intra-operative complications
3) Specimen to pathology: appendix
4) Drains
5) Disposition PACU/ICU
Mr/Mrs ___ is a ____-year old man/woman who was evaluated in the ____ at _____ hospital. She/he
presented with epigastric/right lower quadrant pain of ______duration, fever of ____, (+/- nausea and
- Details of physical examination.
He/she had a white blood cell count of ______. Radiographic studies (CT scan/ultrasound/physical
examination) was consistent with acute appendicitis (non perforated/perforated/abscess/fecalith).
Surgery was indicated and recommended. The risks, benefits, alternative and rationale of surgery
explained including the risk of not operating. Informed consent was obtained for a laparoscopic possible
open appendectomy, which we performed today.
The patient was brought to the operating room where a surgical safety checklist was performed.
Preoperatively, ___ grams of IV Ancef/Vacomycin was administered and prophylactic enoxaparin was given.
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 left lower quadrant 5/10/12 mm port and a 5/10/12 mm supra-pubic port.
- Additional trocars were/were not placed because __________.
The patient was placed in Trendelenburg position with the left side down.
The peritoneal cavity was inspected. The RLQ had:
- (acute simple appendicitis)
- (purulent free fluid)
- (erythematous, injected tissue)
- (moderate sized pelvic intra-abdominal abscess)
- (necrotic appendix)
We began our dissection by following the tenia of the cecum to the base of the appendix. The position of
the appendix was retro-cecal/pelvic/mid abdomen. The appendix was/was not easily identified. The
peritoneum of the inflamed mesoappendix was divided using electrocautery. The appendiceal artery was
identified. The artery was:
- (small and therefore divided with cautery)
- (prominent and therefore divided between clips placed proximally and distally on the vessel)
The appendix was freed/unfolded and the tip was identified. The position of the appendix was retrocecal/pelvic/mid abdomen. The remainder of the mesoappendix was/was not dissected. The base of the
cecum was/was not healthy.
If ligated: divided between endo-loops using laparoscopic scissors
If stapled: An endoscopic linear cutting stapler was then used to divide and staple the base of the
appendix. [It was reloaded with a vascular cartridge and the mesoappendix similarly divided].
The base of the cecum was inspected and found to be intact.
The appendix was placed in a sterile endoscopic bag
- The RLQ and pelvis were suctioned of purulent fluid. Irrigation of the RLQ & pelvis was also performed.
The appendix was removed from the abdomen and sent to pathology (with/without an endoscopic bag
through the ____ port). Good hemostasis was achieved and all ports were removed under direct vision.
The fascia at the supra-umbilical port was re-approximated in a figure-of-eight fashion using the
previously placed 0 vicryl sutures.
- If other ports required fascial closure: re-approximation of the fascia of the ______ ports was done
in a figure-of-eight fashion.
- If no other ports required fascial closure: All remaining incisions were closed using 4-0
(vicryl/biosyn) sutures in a/an (continuous/interrupted) sub-cuticular fashion.
The operative field was cleaned and dried. Steri-strips/dressings were applied. There were/were not no
intra-operative 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.

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

NOTE: Should only be used for routine operations. For more challenging operations, a modified template may be