Xuanwu Hospital of Capital Medical University
Surgical Record Hospitalization Number: XXXXXX
Name: Wang Yuehua, Department of General Surgery, Xuanwu Hospital, Capital Medical University
Sex Female
Age Age
Department of general surgery 1
Bed number 504-5
Preoperative diagnosis: gallbladder polyp-like lesion, 80% gallbladder contraction rate 2 hours after meal.
Intraoperative diagnosis: same as preoperative diagnosis
Operation name: combined laparoscopic choledochoscopy with cholecystectomy polyp removal
Surgeon: Deputy Chief Physician Yuehua Wang
Name of assistant
Operation time: November 2009, 15:20, finished at 17:20
Anesthesia method: general anesthesia
Bleeding volume: 10ml
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 1.2 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 operating forceps were inserted to assist in the exploration. The gallbladder was seen to be normal in appearance, about 6×2.8 cm, a few adhesions were seen in the neck of the gallbladder, the common bile duct was about 7 mm in diameter, no abnormalities were seen in the liver and gastrointestinal tract, and there was no significant intra-abdominal exudation. It was decided to proceed with cholecystectomy polyp removal.
Firstly, two stitches were sutured at the bottom of the gallbladder to support the suture, and the gallbladder was suspended from the puncture points of No. 3 and No. 4, respectively, and a small opening of about 0.8 cm in length was cut at the bottom of the gallbladder and the bile inside was aspirated with a suction device. 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. A gallbladder polyp, about 1.3×0.8 cm in size, with a 2 mm diameter tip attached to the gallbladder, was seen at the bottom of the gallbladder, with no infiltration. The polyp was removed by clamping the tip of the polyp, and the polyp was removed and sent for rapid cryopathology, which was reported as a gallbladder polyp. Three gallbladder polyps, about 0.5 cm in size, were seen on the left side of the gallbladder body near the bed of the gallbladder, and the polyps were removed by clamping the tips of the polyps separately. There was a small amount of bleeding at the tip of the polyps, which was stopped by compression and rinsed with norepinephrine saline to stop the bleeding, and there was basically no bleeding under cholangioscopy. The incision at the bottom of the gallbladder was closed with continuous sutures using No. 4 absorbable sutures, and the dangling thread was removed. The abdominal cavity was rinsed and the bottom of the gallbladder was sprayed with medical adhesive to prevent bile leakage. A 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 dressings 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 aspirated fluid was filtered, tissue fragments were identified, and the specimens were sent to pathology after being shown to the patient’s family.
Intraoperative specimen taken for pathology
□1 yes 2 no
Signature of surgeon: Record date November 2009