Free Professional Surgery Note Template
Professional Surgery Note
Patient Name: Philip Mitchell
Date of Surgery: October 23, 2050
Surgeon: Dr. [Your Name], MD
Procedure: Laparoscopic Cholecystectomy
PREOPERATIVE DIAGNOSIS:
Cholelithiasis with cholecystitis
POSTOPERATIVE DIAGNOSIS:
Cholelithiasis with cholecystitis
ANESTHESIA:
General anesthesia
INDICATIONS:
The patient is a 44-year-old male with a history of recurrent abdominal pain, nausea, and vomiting due to gallstones confirmed by ultrasound. After discussing the risks and benefits, the patient consented to undergo laparoscopic cholecystectomy.
PROCEDURE:
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The patient was brought to the operating room and placed in the supine position. After induction of general anesthesia, the abdomen was prepped and draped in a sterile manner.
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A small incision was made at the umbilicus, and a Veress needle was inserted to establish pneumoperitoneum.
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Three additional trocars were placed in the right upper quadrant.
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The gallbladder was identified, and the cystic duct and cystic artery were dissected using electrocautery.
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The cystic duct was clipped and divided. The cystic artery was similarly clipped and divided.
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The gallbladder was dissected from the liver bed and removed through the umbilical port.
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Hemostasis was achieved, and the ports were closed in layers with absorbable sutures.
FINDINGS:
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The gallbladder was distended with multiple calculi and inflammation present. No evidence of biliary duct injury was observed. The liver appeared normal without any lesions.
ESTIMATED BLOOD LOSS:
Minimal (<50 mL)
SPECIMENS:
The gallbladder was sent for pathological examination.
POSTOPERATIVE PLAN:
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The patient will be monitored in the recovery room until fully awake.
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Pain management will be provided as needed.
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Encourage early ambulation.
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Discharge instructions will include a diet as tolerated and follow-up in one week.
COMPLICATIONS:
None were noted during the procedure.
SIGNATURE:
Dr. [Your Name], MD
Board-Certified General Surgeon
