Xuanwu Hospital of Capital Medical University
Surgical Record Hospitalization Number: XXXXXX
Name: Wang Yuehua, Department of General Surgery, Xuanwu Hospital, Capital Medical University
Sex Male
Age 49 years old
Department of general surgery 1
Bed number 505-1
Preoperative diagnosis: gallbladder stones, postprandial gallbladder contraction rate of more than 90%.
Intraoperative diagnosis: same as preoperative diagnosis
Operation name: combined laparoscopic choledochoscopy for gallbladder stone removal
Surgeon: Deputy Chief Physician Yuehua Wang
Name of assistant
Operation time: May 2009, 9:30 pm, finished at 11:20 pm
Anesthesia method: general anesthesia
Bleeding volume: 3ml
Blood transfusion volume: 0ml
Surgical procedure, intraoperative conditions and treatment.
After successful general anesthesia, the patient was routinely disinfected with iodine and alcohol and towels were laid. A subumbilical transverse incision of about 1.0 cm in length was taken, a pneumoperitoneum needle was inserted to establish a pneumoperitoneum, and a Trocar (No. 1) was inserted to enter the scope for exploration.
Three more punctures were made in the subxiphoid process (No. 2), right midclavicular line under the rib margin (No. 3) and right anterior axillary line under the rib margin (No. 4), respectively, and Trocar and manipulation forceps were inserted to assist in the exploration. The gallbladder was seen to be normal in appearance, about 7×2.8 cm, with no adhesions around the gallbladder, the common bile duct was about 7 mm in diameter, no abnormalities were seen in the liver and gastrointestinal tract, and no significant intra-abdominal exudation. It was decided to proceed with cholecystectomy for stone removal.
Firstly, one stitch was sutured at the base of the gallbladder to support the suture, and the gallbladder was suspended outside the body by drawing out from the puncture point of No. 3. The choledochoscope was inserted into the abdominal cavity from the No. 3 puncture trocar and into the gallbladder, and the normal mucosa of the gallbladder was observed, with no inflammatory congestion or erosion. Cholesterol crystals were found in the bile, which was flushed out and aspirated. A dark brown stone of about 1.0×0.8 cm in size was seen at the bottom of the gallbladder and was removed with a lithotripsy net. The gallbladder was flushed with saline and observed under choledochoscopy without bleeding. With a No. 4 absorbable suture, the incision at the bottom of the gallbladder was closed with consecutive sutures and the suspension wire was removed. The abdominal cavity was rinsed and the bottom of the gallbladder was sprayed with medical adhesive to prevent bile leakage. A fine silicone drainage tube was placed near the bottom of the gallbladder, which was led out of the body from the No. 4 puncture hole and fixed. The dressing and instruments were counted correctly, the mirror was withdrawn, the Trocar was removed, and the small incision was sutured, and the operation was completed.
The operation went smoothly, the patient’s vital signs were stable, and the anesthesia was satisfactory.
Intraoperative specimens were seen: the removed gallbladder stones were sent to the patient’s family.
Intraoperative specimens were taken and sent to pathology
□1 yes 2 no
Signature of surgeon: Record date May 2009