Laparoscopic Appendictomy Dictation

LAPAROSCOPIC
APPENDECTOMY DICTATION
Dr.Hassan’s operative notes for laparoscopic appendectomy in a nutshell
 Note:
o This operative note was taken from surgical books and tailored as what we are doing in our
institution.
o This note is only to guide you in your post operative dictation and it should not be always the
same.
o You can manipulate the note according to the actual operation done in your institution.
o Some surgeons have different techniques so you have the right to manipulate the note.
[DATE]
[COMPANY NAME]
[Company address]
Preoperative Diagnosis: Acute Appendicitis.
Procedure: Laparoscopic Appendectomy.
Postoperative Diagnosis: Same
Anesthesia :
 General anesthesia with endotracheal intubation and assisted mechanical ventilation.
Position of patient:
 Initially supine with arms abducted and extended, Then after induction of pneumoperitoneum the
patient is placed in Trendelenburg position with right side up.
Procedure :
 Time-outs were performed using both pre-induction and pre-incision safety checklists to verify correct
patient, procedure, site, and additional critical information prior to beginning the procedure
 Pre-operative antibiotics given as per policy.
 Pneumatic compression device applied to lower extremity and turned on.
 Antiseptic prepping and draping done; From midchest to lower abdomen.
 intra-abdominal pressure is preset to 15 mm in automatic insufflator. supraumbilical small incision is
made and hasson’s open technique used for insertion of main 10 mm trocar.
 Using a J needle a stay suture taken for later closure of the port site.
 Insufflation tube is connected to the trocar and Establishment of pneumoperitoneum done.
 A 10 mm 30-degree camera is inserted into the peritoneal cavity through the supraumbilical trocar.
 Inspection of the peritoneal cavity done.
 Introduction the next two ports are made under direct vision:
o 5 mm port was inserted above the symphysis pubis and below the hair line.
o 5 mm port was inserted in the Left lower quadrant lateral to rectus sheath.
 The cecum was manipulated with a grasper and the appendix was identified.
 The appendix was then grasped with a Babcock forceps and elevated exposing the base of the appendix.
 The appendix was noted to be inflamed/gangrenous/perforated.
 A window was developed in the mesoappendix at a point between the base of the appendix and the
cecum.
 The mesentery was serially divided with clips/cautery/ultrasonic shears.
 A pre-tied endoloop was then passed over the appendix and snugged tight at the base.
 A second endoloop was similarly placed distal to the first.
 The appendix was divided in between the two endoloops using an endoscopic shear.
 The appendix was placed into an endoscopic retrieval bag and removed via the 10-mm port site.
 The appendiceal stump was then irrigated and hemostasis was assured.
 Fluid was suctioned from the right lower quadrant and pelvis. The terminal ileum was run and found to
be normal with No other pathology identified.
 All ports removed under vision and heamostasis maintained by diathermy.
Closure and disposition:
 Camera port closed using the previously established suture.

 Other port sites closed in subcuticular manner.
 Steri-Strips applied and dressing done for the wounds.
 The patient was extubated in the OR he tolerated the procedure well and shifted to post-anesthesia care
unit in good condition.
Postoperative management:
 Keep the patient NPO until the patient is fully awake then start the patient on soft diet and advance as
tolerating.
 Keep the patient on Intravenous fluid in form of D5NS at a rate of 100 ml/h and stop as the patient is
tolerating orally.
 Ambulate the patient as early as possible.
 Teach the patient how to use incentive spirometry and encourage its usage.
 Analgesia :
o Injection Perfalgan 1G Intravenous QID.
o Injection pethidine 75 mg Intramuscular TID PRN for severe pain.
 Antibiotics:
o inj. cefuroxime 1.5 G Intravenous TID.
o inj. Metronidazole 500 mg intravenous TID.
 GI prophylaxis :
o Injection Pantoprazole 40 mg Intravenous once daily.
 DVT prophylaxis :
o Keep the patient on pneumatic compression while on bed.
o Keep the patient on injection Clexane 40 mg Subcutanouse once daily.
 Antiemetic:
o Keep the patient on ondansetron 8 mg IV TID PRN if nausea or vomiting.
 Monitoring of pulse, blood pressure, respiration, temperature and urine output.
 Surgical drain care as follow ( if there is any ):
o keep drain on negative pressure.
o monitoring of its output including, color, amount

Laparoscopic Appendictomy Dictation

Uploaded by

Copyright:

Available Formats

Laparoscopic Appendictomy Dictation

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Laparoscopic Appendictomy Dictation

Uploaded by

Copyright:

Available Formats

LAPAROSCOPIC

Procedure: Laparoscopic Appendectomy.

Postoperative Diagnosis: Same

 General anesthesia with endotracheal intubation and assisted mechanical ventilation.

Closure and disposition:

 Camera port closed using the previously established suture.

You might also like