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:
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.
A small incision was made at the umbilicus, and a Veress needle was inserted to establish pneumoperitoneum.
Three additional trocars were placed in the right upper quadrant.
The gallbladder was identified, and the cystic duct and cystic artery were dissected using electrocautery.
The cystic duct was clipped and divided. The cystic artery was similarly clipped and divided.
The gallbladder was dissected from the liver bed and removed through the umbilical port.
Hemostasis was achieved, and the ports were closed in layers with absorbable sutures.
FINDINGS:
ESTIMATED BLOOD LOSS:
Minimal (<50 mL)
SPECIMENS:
The gallbladder was sent for pathological examination.
POSTOPERATIVE PLAN:
The patient will be monitored in the recovery room until fully awake.
Pain management will be provided as needed.
Encourage early ambulation.
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
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