Question

Operative Report Patient Name: Jeanne Waters Birth Date: 04/211936 Patient Number: 67-53-22 Room Number: 323 DATE OF PROCEDURE: 05/04/xx PREOPERATIVE DIAGNOSIS: Acute cholecystitis with cholelithiasis POSTOPERATIVE DIAGNOSIS: Acute purulent cholecystitis with gangrenous change in wall and early perforation and localized peritonitis. PROCEDURE PERFORMED: Cholecystectomy with operative cholangiography SURGEON: Robert E. Lee, MD ASSISTANT: E M. Grant, MD PROCEDURE: The patient was placed supine on an operating table and a general endotracheal anesthetic was administered uneventfully by Dr. Morse. The abdomen was prepared with heavy cleansing alcohol. The operating field was draped in sterile towels and sheets. A primary right subcostal incision was used in this very large (about 250 pounds) patient with an extremely generous abdomen. Upon opening the peritoneal cavity, it was noted immediately that the gallbladder was quite inflamed and the omentum was packed around it. There was a fibrinous exudate overlying parts of the omentum but this could gradually be released revealing a markedly thickened and reddened gallbladder consistent with acute cholecystitis. In addition, on its medial portion of the wall, there was a gangrenous area that showed evidence of perforation and a purulent collection of about 25 cc of material as well as the fibrinous exudate. This was cultured for aerobic and anaerobic organisms. The gallbladder was released from the gallbladder fossa starting at the fundus and working to the neck, and because of the intense inflammation, this patient had marked vascular changes in the liver bed. These were packed away as dissection proceeded which could be done essentially with a finger until reaching a thickened area at the neck of the gallbladder. In this portion, very careful and gradual blunt dissection was performed identifying the cystic artery which was clamped divided and doubly ligated with 2-0 Tedek and then clipped with a metallic staple. The cystic duct was identified in this patient, it was quite short measuring not more than 10 mm in length and extending into the common duct which could be visualized below and the common hepatie duct above. The neck of the gallbladder was tied with 2.0 Tevdek. The cystie duct was opened. Common clear bile escaped. Two operative cholangiograms using hall strength radiopaque dye of about 10 e cach injection were obtained showing no evidence of filling defects and ready entrance of dye into the duodenum. The cystic duct was then clamped and doubly tied with the 2.0 Tedek adjacent to the common duct but no impinging on it. As the films were being developed, the rest of the gallbladder was being released by blunt dissection and totally Temoved intact Not mentioned previously was that it was first decompressed before dissection was performed placing a purse string suture at the funds and releasing all the purulent bile with a trocar and this bile was also cultured for acrobic and anaerobic organisms Now going on the operative areas were inspected gradually and slowly, and hemostasis obtained with electrocoaculation. Unfortunately, our coagulating mechanisms sent off alarms apparently from her pacemaker or the right hip prosthesis so that several of these were tried. Fortunately, a satisfactory connection could be obtained and electrocoagulation proceeded to a satisfactory level In this patient, the liver was quite friable throughout. In all areas where there were raw surfaces, either Gelfoam or Surgicel packs were placed and hemostasis appeared secure when all of this was completed The operative areas were lavaged with copious physiologic saline, returns were clear. Two one inch Penrose drains were placed in the infrahepatic space and brought out through a separate inferior stab wound. The intestinal contents were replaced

Answer 1

1. Procedure performed was Cholesystecomy with operaive cholangiography defined as the removal of the gall bladder with visualizatin of the bile duct by x-rays and and injection of contrast medium.

2. The gall bladder was quite inflammed and omentum was packed around it. There was a fibrinous exudate overlying parts of the omentum but this could gradually be released revealing a markedly thickened and reddened gall bladder consistent with acute cholecystisis.

3. On the medial portion of the wall there was gangrenous area that showed evidence of perforation and a purulent collection of about 25 cc of materials as well as the fibrinous exudate.

4. Hemostasis obtained with elecrocoagulation, coagulating mechanism sent off alarms apparently from her pacemaker or the right hip prosthesis

5. Satisfacory connection could be obtained and elecrocoagulation proceeded satisfacory.