Preop Diagnosis - Need for tissue diagnosis
Postop Diagnosis - Same
Surgeon - Dr. Luk / Dr. Tran
Assistant Surgeon -
Anesthesia - General anesthesia
Estimated Blood Loss - Minimal
Complication - none
Findings -
Specimen -
Peritoneal Washing
Omental Biopsy
Peritoneal Biosy
Procedure performed - Diagnostic Laparoscopy with Biopsy
Patient comes in with the above diagnosis and was consented for the above procedures. Risks, benefits, and alternatives were discussed with patient, which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, injury to other organs, or need for further procedures or workup. Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications. The patient understand and agrees to proceed with the proposed procedure.
The Patient was given preoperative antibiotics.
After consent was obtained, the patient was brought to the OR and underwent general anesthesia. The patient was prep and draped in the standard manner.
Timeout was performed and all was in agreement.
A small incision was made at the umbilicus using the number 11 blade. Dissection was carried down to the fascia using the retractors. Once the fascia was opened, a trocar was placed into the abdomen. Next, CO2 gas was used to insufflate the abdomen. Examination of entrance site did not reveal any injury to the intra-abdominal structures during the entrance process. The pt was placed into position.
Next, additional incisions were made and trocars were placed the abdominal cavity. These were placed in the standard locations for laparoscopic diagnostic and biopsy
Describe Findings Here ----------------------------------
Finally, the specimen was removed from the abdominal cavity through the umbilical trocar site in its entirety without complication. C02 was released from the abdominal cavity and the trocars were then removed, no bleeding at sites.
At the end of the case, counts were carried out. When instrument, sponge, and needle
counts were completed and reported to me as correct, then I began the closure. Local anesthetic injected at the sites. Skin approximated with 4 Monocryl suture.
The patient tolerated the procedure well , no complications, extubated, and was transferred to the recovery room in stable and satisfactory conditions.