1. Laparoscopic-assisted open cholecystectomy.
DESCRIPTION OF OPERATION: The patient was positioned supine on the operating room table. Pneumatic compression stockings were applied and inflated. After induction of adequate general endotracheal anesthesia, an indwelling Foley catheter was placed to gravity drainage. The abdomen was prepped and draped in the usual sterile fashion. A small umbilical incision allowed for introduction of the Veress needle and inflation of the abdomen to 15 cm of water pressure using carbon dioxide gas. The 0 degree, 5 mm laparoscope was introduced through a 5 mm port at the umbilicus and 3 additional ports were placed in the usual anatomic positions. The liver was found to be markedly enlarged. The gallbladder was markedly inflamed and dissection at the infundibulum of the gallbladder was extremely difficult due to the overwhelming size of the liver. After approximately 20 minutes of trying to mobilize the gallbladder, the decision was made to convert the operation to the open form.
The upper subcostal incisions were connected and a formal 12 cm subcostal incision was created and dissection taken down through the anterior abdominal wall fascia and musculature until the peritoneum was carefully incised. Retractors were placed and the colon was packed inferiorly and away from the field. The stomach was packed to the left and the gallbladder was readily exposed. A Kelly clamp was used to control the gallbladder and dissection begun in an antegrade fashion, beginning at the fundus and dissecting along the length of the gallbladder. Marked inflammation led to continuous bleeding within the liver parenchyma, all of which was controlled with high wattage cautery. Continued dissection down toward the infundibulum of the gallbladder revealed a large 2.4 cm stone impacted in the neck of the gallbladder. The stone was ultimately retrieved. Continued dissection allowed for identification of an inflamed cystic duct, which was of poor tissue quality. The duct was preserved. Two clips were used to control the duct distally and one proximally. The cystic duct was transected with excellent hemostasis. The gallbladder was sent as specimen along with the stone. The bleeding from the liver bed was controlled.
During the laparoscopic dissection, a small rent in the liver adjacent to the gallbladder fossa produced a large volume of pus. This was explored further, and an index finger was introduced into the liver abscess cavity and from the gallbladder fossa pointed anteriorly. A second incision was made on the dome of the liver using the cautery, and the entire abscess cavity was opened in this fashion. Two 0.5 inch Penrose drains were advanced through the liver and brought up to the level of the skin thereby completely draining the liver abscess. Once again, an index finger was introduced into the liver and any loculated areas were broken up and completely irrigated out. All irrigant was aspirated. The right upper quadrant was then irrigated and aspirated completely including the subdiaphragmatic space. A 19-French Blake drain was left in the gallbladder fossa and brought out through a separate stab incision in the right upper quadrant. The liver was partially packed using 1-inch iodoform gauze, which was brought up with the Penrose drains. The Penrose drains were sutured to the skin edges of the incision.
The fascia and abdominal wall musculature were closed as a single layer using interrupted 1 Vicryl suture. The drains were allowed to come up through the incision, and the skin was closed using surgical staples. Bulky dressings were applied throughout. All of the existing laparoscopic incisions were closed with staples. Marcaine 0.25% with epinephrine was used to infiltrate the skin and subcutaneous tissue at all incisions. The patient was awakened, extubated, and moved to the recovery room in satisfactory condition. She tolerated the procedure well. Needle and sponge counts were correct at the end of the procedure. Instrument counts were also correct.
1. Symptomatic cholelithiasis.
1. Chronic calculus cholecystitis.
OPERATION: Laparoscopic cholecystectomy.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF PROCEDURE: With the patient in the main operating room under adequate general endotracheal anesthesia, Zosyn was given at the time of induction. The entire abdomen was prepped with iodoform and draped in usual sterile fashion. A small infraumbilical incision was made and carried through the subcutaneous tissue down to the fascia, which was cleaned off and elevated using Kocher forceps. A Veress needle was then placed through the fascia onto the peritoneal cavity. A positive saline test was obtained. Pneumoperitoneum was then established up to 17 mm of pressure and a 10-mm trocar was then placed through this incision. A 0-degree, 10-mm laparoscope was then placed through this trocar.
Attention was first directed to the pelvis where no gross abnormalities were seen. Both internal rings were found to be closed. At this point, the patient was placed in reverse Trendelenburg position. Both lobes of the liver were inspected and appeared to be grossly normal with no masses or lesions identified. At this point, two 5-mm trocars were placed in the right upper quadrant and were used to elevate the gallbladder. Upon elevating the gallbladder, there were marked adhesions of both the transverse colon and duodenum to the gallbladder.
At this point, the 10-mm trocar was placed about midline adjacent to the xiphoid. At this point, using careful traction along with Harmonic scalpel, we were able to take down all these adhesions carefully. Care was taken to identify both the transverse colon and duodenum throughout its entire area of adhesions to gallbladder so as not to injure these adjacent organs.
At this point, attention was immediately directed to the triangle of Calot with the cystic duct very nicely seen and isolated. This was seen very nicely as it entered into the gallbladder. This was then endoclipped three times on the patient’s side, one on the specimen and transected.
At this point, pneumoperitoneum was then reestablished again. The subhepatic and subdiaphragmatic region was quite thoroughly irrigated using close to almost 2000 mL of normal saline with good clear aspirate return. There was also very nice hemostasis within liver bed.
At this point, all the trocars were removed under direct visualization. No bleeding was encountered. The small infraumbilical fascia was approximated using 0 interrupted figure-of-eight PDS. All the incisions were infiltrated using 0.25% Marcaine. These were then approximated using 4-0 Vicryl along with Steri-Strips and sterile dressing. The estimated blood loss was minimal. None was transfused. No drains were placed. Sponge, needle and instrument counts were correct x2 at the end of the case. The patient subsequently tolerated the procedure well, and she was then returned to the recovery room in a very stable condition.
PREOPERATIVE DIAGNOSIS: Chronic anal fissure and anal stenosis.
POSTOPERATIVE DIAGNOSIS: Chronic anal fissure and anal stenosis.
1. V-Y anoplasty.
ESTIMATED BLOOD LOSS: 30 mL.
SPECIMENS: No specimens.
DRAINS: A 0.25-inch Penrose to the flap.
DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the OR. She was placed in the prone jackknife position and IV sedation was given by the anesthesiologist. The buttocks were taped laterally, exposing the perianal area. I began with the lubricated scope. The videoscope was inserted into the rectum and advanced through the colon to about 40 cm. At 40 cm, there was some angulation and some looping of the scope, and I elected not to proceed beyond this point. I then began to slowly withdraw the scope, carefully inspecting the lumen. The prep was adequate up to this point. I withdrew the scope. I noted no tumors or polyps. There was no evidence of colitis or proctitis and no diverticular disease was noted. I then desufflated the colon and rectum and removed the scope.
The perianal area was then prepped with Betadine and draped in the usual fashion. I then used a solution of 0.5% Marcaine with epinephrine and injected about 30 mL perianally as well as intramuscularly to achieve some relaxation of the sphincter muscles. After adequate analgesia was obtained, the small Ferguson retractor was inserted and the anal canal was inspected. The anterior fissure was very chronic appearing and measured about 1 x 0.5 cm in size. The anal canal was rather small and there seemed to be spasm of the distal edge of the internal sphincter muscle.
I then inserted the Buie retractor and opened it to expose the right lateral anal canal. An incision was made over the anoderm in the right lateral position and then I dissected down to the distal edge of the internal sphincter muscle, which was easily palpable as a tight band. I used a hemostat to dissect underneath it and elevated and divided it for a length of less than 1 cm. This did achieve relaxation of the sphincter muscle.
Then at this point, I was able to remove the Buie retractor and inserted the Chelsea-Eaton retractor. There was a definite release of the spasm of the sphincter muscle. However, there was also now obvious evidence of stenosis of the anal canal and there was no way to bring the mucosal edges together to cover the sphincterotomy wound without putting tension on the anal canal. Because of this, I did elect to go ahead with the anoplasty.
I used a marking pen to outline a house-shaped flap on the perianal skin in the right lateral position. I then anesthetized this area. I used a #15 blade scalpel to incise the skin edges. I then mobilized the flap by dissecting laterally to give the flap a very broad base. With the lateral dissection, I was then able to mobilize the flap down into the anal canal to cover up the lateral internal sphincterotomy wound.
The area was irrigated. Then the flap was sewed into place using interrupted sutures, using combination of #3-0 Vicryl and #4-0 Vicryl sutures, using the #3-0 Vicryl primarily on the tension points of the flap. Once the proximal edge of the flap was sewed to the dentate line, I then came up the anterior and posterior sides of the flap suturing again in an interrupted fashion to the cut mucosal edges. I then used a scalpel to make a small incision in the right posterior position about 1 centimeter or 2 away from the flap and then used the stab incision to bring a 0.25-inch Penrose through the skin and positioned it underneath the flap. It was sutured to the skin with a single #3-0 Vicryl suture. The excess drain was then cut away, leaving about 2 or 3 cm protruding and the remainder positioned underneath the flap. I then used #2-0 Vicryl and a mattress suture to perform the long portion of the Y of the flap. This was done on the distal edge of the incision bringing the two skin edges together with two of these mattress sutures to form the Y.
I then directed my attention back toward the anal fissure in the anterior position. The small anterior tag was excised. That was a small hypertrophied anal papilla. I then mobilized the mucosal side of the fissure, elevating the mucosa, and a very small amount of muscle as well and then used a #4-0 Vicryl suture to bring this mucosal edge up about half way up the fissure to partially cover it and facilitate the healing process. There was a small amount of bleeding that was controlled with the #3-0 Vicryl figure-of-eight suture.
At this point, I had good release of the anal stenosis and good hemostasis throughout. On further examination, there was a very small posterior anal fissure, which was simply coagulated with the electrocautery. At this point, the retractor was removed. A roll of Gelfoam was placed in the anal canal and then a fluffy gauze dressing was placed over the Gelfoam.
The patient was then returned to the supine position and taken to the recovery area in stable condition.
PROCEDURE: Needle-localized biopsy, right breast.
DESCRIPTION OF PROCEDURE: After proper consent was obtained, the patient was brought to the operating room and placed on the table in a supine position. Monitored anesthesia care with intravenous sedation was administered. The patient tolerated this well. The right breast area was prepped and draped in a sterile manner. Plain Marcaine 0.5% solution was injected for local anesthesia in the perioperative region. A curvilinear incision was made medial to the insertion site of the wire, as the wire was noted to pass medially in the breast. The preoperative localization films were reviewed, noting that the clip was posterior to the wire. The dissection was carried out with cautery to remove a core of tissue around the wire, being more generous on the posterior aspect around the wire and especially near the end of the wire, taking a very generous area of tissue posteriorly; in fact, it was all the way down to the pectoralis fascia at that site. The specimen was removed, noting that the wire was within the mid portion of removed tissue with a large amount of surrounding tissue. This was submitted for radiographic analysis and the wire was noted to be within the large specimen. However, the clip could not be visualized. For this reason, the operative area was inspected with fluoroscopy with diligence and there was no evidence of any residual clip within the right breast tissue or within the drapes around the right breast. The Ray-Tec sponge was also evaluated with fluoroscopy and direct inspection and no clip was noted. The suction canister and tubing were also evaluated with fluoroscopy and no clip was noted. At this point, due to the generous size of the biopsy specimen, decision was made to not blindly remove any further breast tissue. I suspect that the clip may have become stuck to a Ray-Tec sponge or other instrument during this procedure and came out of the wound and fell out of the field of dissection. The operative area was irrigated, noted to hemostatic, and closed in layers using interrupted #3-0 Vicryl suture to close deep dermis and running #4-0 subcuticular Vicryl suture to close the skin. Benzoin, Steri-Strips and sterile gauze dressings were placed. The patient had her sedation stopped and she was taken to the recovery area.
OPERATION: Laparoscopic cholecystectomy.
DESCRIPTION OF OPERATION: On the day of surgery, the patient was brought to the operating room and placed supine on the operating table. After administration of adequate general anesthesia, the abdomen was prepped and draped in the standard surgical fashion. Attention was then drawn to the left upper abdomen, where a small stab incision was made. The Veress needle was inserted. The abdomen was insufflated with carbon dioxide gas to a pressure of 15 mmHg. A 12 mm Endopath bladeless trocar was loaded on to the camera. A small infraumbilical incision was made in the midline. The abdomen was then entered using the bladeless trocar to visualize the abdominal wall areas on the screen. Gas was placed on to this trocar. The area of the insertion of this Veress needle was seen. There was no evidence of any injury or bleeding. An additional 12 mm trocar was placed in the standard position in the epigastrium. Two additional 5 mm trocars were placed in the right upper abdomen. Gallbladder was grasped and retracted cephalad and laterally. Dissection was next carried out and the cystic duct was clearly identified entering the gallbladder. Pictures of the gallbladder as well as dissection of the cystic duct were taken and placed in the chart. Cystic duct was then clipped with 2 clips on the proximal side, one on the gallbladder side, and transected. Further dissection was next carried out. The cystic artery was clearly identified entering the gallbladder, and it too was clipped and transected in a similar fashion. Attachments of the gallbladder to the liver bed were then taken down using hook Bovie electrocautery maintaining excellent hemostasis. Gallbladder was placed in the specimen bag and removed from the umbilical port site. Area of the liver bed was inspected and excellent hemostasis achieved. The ports were removed under direct visualization. The fascial defect at the umbilical port site was closed using a figure-of-eight 0-Vicryl suture. The wounds were infiltrated with 0.25% Marcaine local anesthetic. The 4-0 Vicryl subcuticular sutures were used to bring the skin edges together and Steri-Strips and sterile dressings were applied. All instrument, sponge, and needle counts were correct. The patient was awakened, extubated, and brought to the recovery room in stable condition.
PROCEDURE PERFORMED: Insertion of left internal jugular Infuse-A-Port with fluoroscopy.
DESCRIPTION OF OPERATION: On the day of surgery, the patient was brought to the operating room and placed supine on the operating table. After administration of adequate MAC anesthesia, area of the left chest wall and neck were prepped and draped in the standard surgical fashion. Attention was then drawn to the left subclavian area. Lidocaine 1% local anesthetic was infiltrated. Left subclavian vein was then cannulated with a needle and good blood return was noted. Attempts to pass the wire into the left subclavian vein were unsuccessful. Fluoroscopy was used. The wire was coiling and it felt as if possibly there was a blockage or some obstruction. Therefore, decision was made to abandon that technique and try the left internal jugular approach. At that time, the local anesthetic was infiltrated into the area overlying the left internal jugular vein. This was cannulated using modified Seldinger technique. The wire was passed and went more easily into the superior vena cava. At that point, a small stab incision was made next to the wire. The area of the pocket on the left anterior chest wall, approximately 2 fingerbreadths below the clavicle, was identified. Local anesthetic was infiltrated in the skin and subcutaneous for the pocket creation. The scalpel was used to make an appropriate sized skin incision. Bovie electrocautery was used to dissect free the subcutaneous tissue maintaining excellent hemostasis. The catheter was than passed from the area of the pocket and tunneled all the way up to the wire in the left neck. At that point, the introducer sheath and breakaway dilator were placed over the wire and seen going down the superior vena cava. The catheter was passed. Breakaway introducer sheath was subsequently removed. The catheter tip was seen in the distal superior vena cava and at that point it had been tunneled and appropriately sized and reached the anterior chest wall to a length of approximately 26 cm. It was cut to that length, attached to the port, and had good blood return and flushed easily. The port was secured to the pocket in the anterior chest wall with interrupted 0 Vicryl suture. The skin was brought together with interrupted 3-0 Vicryl deep dermal layer and the skin edges were brought together with 4-0 Vicryl subcuticular suture. Steri-Strips and a sterile dressing were applied. All instrument, sponge, and needle counts were correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition. Stat portable chest x-ray was ordered for the recovery room.
OPERATION: Insertion of P.A.S. port.
DESCRIPTION OF OPERATION: The patient was placed in the supine position. Right arm and chest wall were prepped with Betadine and draped accordingly. Xylocaine 1% with epinephrine was infiltrated just above the antecubital fossa, medial side. An incision was made just above the antecubital fossa, medial side of the right arm. The skin and subcutaneous tissue was divided. Skin flaps were developed. After some blunt and sharp dissection, a small branch of the antecubital vein was identified. Vessel loop was placed on either side of this vessel. A small incision was made in this vessel through which a previously heparinized P.A.S. port catheter was introduced to about 40 cm. Using the cath finder, it appeared that the catheter was going up into the right jugular. The catheter was pulled back. Now, using fluoroscopy, the wire within the catheter was pulled back and the catheter was guided down into the junction of the superior vena cava and right atrium. The wire within the catheter was pulled out. The catheter was tested. It drew back blood easily. It was flushed with heparinized saline and tied in place with a 2-0 silk tie. The vein was tied off distally with a 2-0 silk tie. Fluoroscopy was then again used to confirm position of the catheter, which was at the junction of superior vena cava and right atrium. Now, fluoroscopy was stopped. The subcutaneous tissue was approximated with 2-0 Monocryl and the skin with staples. The patient tolerated the procedure well. The port was tested. It drew back blood easily. It was flushed with heparinized saline. The patient left the operating room in satisfactory condition.
DESCRIPTION OF OPERATION: After adequate induction of general endotracheal anesthesia and the placement of adequate monitoring lines, the patient's abdomen was prepped and draped in the routine sterile fashion. The abdomen was entered through a right lower quadrant subcostal incision. All bleeders were electrocoagulated as encountered. Upon entrance into the peritoneal cavity, manual exploration revealed moderately inflamed gallbladder. Cystic artery and cystic duct were easily located, doubly clipped, ligated, and divided. There was an accessory cystic duct noted, which was also ligated and divided. The gallbladder was taken down from the liver bed without difficulty cauterizing the bed for hemostasis. The wound was irrigated with saline, checked for hemostasis, which was found to be satisfactory. The incision was closed with running #1 PDS for the peritoneum and posterior fascia, running #1 PDS for the anterior fascia, and skin clips for the skin. Final sponge and instrument counts were verified as being correct. Estimated blood loss was minimal. The patient tolerated the procedure well and was returned to the recovery room in stable condition.
OPERATION: Right inguinal herniorrhaphy, Shouldice repair.
DESCRIPTION OF PROCEDURE: After the satisfactory induction of general anesthesia, with the patient in the supine position, he was prepped and draped in the usual fashion. I used a right inguinal incision. The subcutaneous layers traversed, and the external oblique aponeurosis was opened along the direction of its fibers. The ilioinguinal nerve was dissected out. The spermatic cord was likewise dissected out. Then, I dissected the ilioinguinal nerve out of the way and retracted it out of the way. Then, I concentrated my dissection on the spermatic cord and its components. I divided the cremaster muscle and I dissected out the indirect inguinal hernial sac. I opened the sac, and there was a sliding component of omentum in it. I dissected out the omentum and pushed that back into the peritoneal cavity. A pursestring suture of 3-0 silk was placed on the neck of the hernial sac. I excised the rest of the hernial sac.
Then, the cremaster muscles were reapproximated with 3-0 chromic catgut. Then, I performed a Shouldice repair using 0 Prolene. With the first layer of the repair, I imbricated the posterior inguinal wall. With the second layer of the repair, I sutured the transversalis fascia medially with the shelving edge of the inguinal ligament laterally.
Following the repair, the posterior inguinal wall felt nice and firm.
The spermatic cord was then placed back in its normal anatomical position. The ilioinguinal nerve was intact. Then, the external oblique aponeurosis was closed over the spermatic cord with 3-0 silk. The subcutaneous layer was then closed with 3-0 plain catgut. The skin incision was closed with skin staples.
The estimated blood loss was negligible. The patient tolerated the procedure quite well under general anesthesia, no problems.
OPERATION: Left inguinal hernia repair with mesh.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine on the operating room table. After general anesthesia was induced, the left inguinal area was prepped with Betadine solution and sterilely draped in the usual manner for procedure in this area. The skin and subcutaneous tissues of the left inguinal area were anesthetized, and an incision beginning at the left pubic tubercle and extending laterally along natural skin lines was created. The incision was extended through the subcutaneous tissues to the aponeurosis of the external oblique. Hemostasis was obtained with the Bovie cautery. The subaponeurotic tissues were anesthetized.
The aponeurosis of the external oblique was incised along the length of its fibers. Care was taken to avoid the ilioinguinal nerve. At the level of the pubic tubercle, the spermatic cord was bluntly dissected from its surrounding structures and encircled with a 0.25 inch Penrose drain. The direct hernia sac was dissected off of the cord structures and invaginated into the preperitoneal space. A search for an indirect component proved fruitless.
A large Marlex mesh "plug" was placed in the preperitoneal space reducing the direct inguinal hernia. It was anchored to the conjoint tendon and the shelving edge of the Poupart's ligament and the pubic tubercle with 2-0 PDS sutures. The onlay portion was placed over the floor of the inguinal canal, while it was anchored to the shelving edge of the Poupart's ligament to the conjoint tendon and laterally to the internal oblique with interrupted 2-0 PDS sutures. The Marlex mesh plug was attached to the onlay portion with a 3-0 Prolene suture. The aponeurosis of the external oblique was closed with a running suture of 3-0 PDS. Subcutaneous tissues were approximated with interrupted sutures of 3-0 PDS. The skin was closed with subcuticular suture of 4-0 PDS. A 0.5-inch Steri-Strip tape was applied. A sterile occlusive dressing applied over this.
The patient tolerated the procedure well and was transferred to the recovery room in stable condition. Estimated blood loss was 5 cc. Sponge, needle, and instrument counts were correct.
OPERATION: Repair of congenital diaphragmatic hernia with a Gore-Tex patch.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and prepped and draped in a sterile fashion over the abdomen and chest. After induction of general endotracheal anesthesia, a left subcostal incision was made and taken down sharply through the skin and subcutaneous tissue. We divided the anterior sheath and muscular layer followed by the posterior sheath and posterior muscles using electrocautery. We then entered the abdomen and extended the incision along the peritoneum, along the entire length of the abdomen for exposure and visualization. We placed small retractors in the incision, and we were able to visualize a fairly large left-sided diaphragmatic hernia with herniation of most of the abdominal contents into the left chest. We used forceps to gently start removing some of these. The first thing we saw was the colon. We started removing the colon through the diaphragmatic hernia site using forceps, and the colon was pulled out of the left chest fairly easily with forceps. We then identified that there was small bowel also within the hernia and slowly removed the entire small intestine, which was also in the left chest, through the hernia, and this took several minutes to remove all the small bowel back into the abdomen. At this point, there was one more structure that was up in the left chest, and this was the spleen. We gently placed traction on the spleen and used forceps and noncrushing clamps to gently reduce the spleen out of the left chest and back into the abdomen. This was the final structure to be removed, and we did this without any bleeding at this point.
With all of the colon, small intestine, and spleen reduced back into the abdomen, we then planned our repair. We used electrocautery to identify and clean off the edges of the diaphragmatic hernia and placed clamps along the edges before we attempted our closure. Once we had the edges cleared with the electrocautery, we then began placing interrupted #2-0 Vicryl sutures in interrupted fashion along the anterior and posterior openings of the diaphragmatic hernia. We did this along the entire length of the opening, and then, while we attempted to tie these sutures down, we noticed that there was a tear on the more medial portion of the diaphragm and that we would not be able to repair this hernia primarily. Therefore, we used a Gore-Tex patch, which was tailored to fit the size of the remaining defect, and we sutured this in place using the #2-0 Vicryl suture in running fashion along the entire edges of the hernia posteriorly, anteriorly, laterally, and medially, along all the edges of the hernia and did have to take some larger bites posteriorly, close to the ribs, along the posterior border. Once we had our patch in place, we felt that the repair was adequate at this point. The abdominal contents were back in their normal condition. We did run the small bowel; it was normal, there were no atretic areas. The spleen appeared to be healthy. There was no bleeding from it, and the colon was in normal position. There was no malrotation or anything and therefore, at this point, we simply irrigated with some saline. We did place a left-sided chest tube into the anterior chest tube through the fourth and fifth interspace, and this was positioned in the chest under direct visualization and then we sutured the chest tube in place with a nylon suture and then we closed the incision.
We closed the posterior peritoneum and the posterior sheath with a #2-0 running Vicryl suture and then closed the posterior sheath musculature and fascia with another #2-0 Vicryl suture in running fashion and similarly closed the anterior sheath with #2-0 Vicryl suture in running fashion, closed the subcutaneous tissue with #3-0 Vicryl, and then ran a #4-0 Monocryl suture in subcuticular fashion. Steri-Strips and dressing were applied. The patient tolerated the procedure well and was admitted postoperatively.
OPERATION: Laparoscopic appendectomy.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and underwent adequate general anesthesia. Area of the abdomen was prepped and draped in the standard surgical fashion. Attention was then drawn to the supraumbilical area. A small incision was made and carried through the skin and subcutaneous down to the fascia. Stay sutures of 0 Vicryl were placed on both sides of the midline fascia. Fascia was opened. Peritoneal cavity was entered. A 12 mm Hasson trocar was placed. Abdomen was insufflated with carbon dioxide gas to a pressure of 15mmHg. Camera was inserted. An additional 12 mm trocar was placed in the suprapubic position. An additional 5 mm trocar was placed between the two 12 mm trocars in midline under direct vision. The patient was placed in Trendelenburg position, right side up. The cecum was identified. The appendix was seen hanging off of it. It was inflamed and adherent to the attachments around it. Lateral attachments were taken down using harmonic Endoshears, excellent hemostasis. The mesoappendix was also taken with harmonic Endoshears maintaining excellent hemostasis. The base of the appendix was then identified, and the GIA 45 2.5 mm stapler was fired across the base with excellent staple approximation and excellent hemostasis. The appendix was placed in a specimen bag and removed from the abdomen. Inspection of the right lower quadrant was made. No fluid. The trocars were removed under direct visualization and area of the fascial defect at the umbilical site was closed using a figure-of-eight 0 Vicryl suture. The ports were infiltrated with 0.25% Marcaine local anesthetic, and the skin was approximated and closed with 4-0 Vicryl subcuticular sutures. Steri-Strips and sterile dressings were applied. All instrument, sponge, and needle counts were correct. The patient was awakened, extubated, and brought to the recovery room in stable condition.