AI Scribe for General Surgeons

OPERATIVE REPORT
Date of Surgery: 2026-04-22
Surgeon: J. Patel, MD
Assistant: M. Cho, MD (PGY-4)
Anesthesia: General endotracheal (Dr. Romero, anesthesiology)

PRE-OPERATIVE DIAGNOSIS:
Acute calculous cholecystitis (K80.00)

POST-OPERATIVE DIAGNOSIS:
Acute gangrenous cholecystitis with pericholecystic abscess (K81.0)

PROCEDURE PERFORMED:
Laparoscopic cholecystectomy with intraoperative cholangiogram (CPT 47563)

ASA CLASS: III (poorly controlled DM2, BMI 34, prior MI 2021)
NPO STATUS: NPO since midnight, 14 hours pre-op
ANTIBIOTICS: Cefazolin 2 g IV at 07:42, 18 minutes before incision

INDICATION:
52-year-old female, BMI 34, with 3 days of progressive RUQ pain radiating to right scapula, fever to 38.9°C, WBC 16.8, total bilirubin 1.4. RUQ ultrasound (radiology read by Dr. Hsu) showed gallbladder wall thickness 7 mm, pericholecystic fluid, and a 2.1 cm impacted neck stone with sonographic Murphy sign. Risks of bleeding, infection, bile duct injury (1 in 200 to 1 in 600), retained stone, conversion to open, and need for ERCP discussed in detail. Patient consented in clinic and again in pre-op holding.

FINDINGS:
- Severely inflamed, gangrenous gallbladder with overlying pericholecystic abscess approximately 4 cm in diameter
- Dense fibrinous adhesions from omentum and duodenum to the gallbladder fossa
- Critical view of safety achieved after careful dissection
- Cystic duct 4 mm, cystic artery posterior in roughly 30 percent of cases — confirmed prior to clipping
- Cholangiogram demonstrated normal biliary anatomy, no filling defects, free flow of contrast into duodenum
- Liver surface smooth, no evidence of cirrhosis or metastatic disease

PROCEDURE:
Patient brought to OR and placed supine. Time-out performed. General anesthesia induced and ETT secured atraumatically. Abdomen prepped with chlorhexidine and draped in standard sterile fashion.

Pneumoperitoneum established with Veress needle technique at the umbilicus, opening pressure 4 mmHg, insufflated to 15 mmHg with no abnormal resistance. A 12 mm optical trocar was placed under direct vision at the umbilicus. Three 5 mm working trocars placed in the standard French (American) configuration: epigastric, right midclavicular, and right anterior axillary line.

Initial diagnostic laparoscopy revealed dense adhesions to the gallbladder. Adhesions were taken down sharply and with the LigaSure. The gallbladder was decompressed by needle aspiration of approximately 60 mL of cloudy bile. The infundibulum was retracted laterally to expose Calot's triangle. Hartmann's pouch was carefully dissected from the cystic plate. The critical view of safety was achieved: only two structures entering the gallbladder, lower one-third of the gallbladder dissected off the liver bed, and the hepatocystic triangle cleared of fat and fibrous tissue.

Intraoperative cholangiogram performed via cystic duct cannulation with a Reddick-Olsen catheter. Two 30-second fluoro images obtained — biliary tree filled normally to right and left intrahepatic ducts, no filling defects, contrast flowed freely into the duodenum.

Cystic duct doubly clipped proximally and distally with 5 mm clips and divided. Cystic artery clipped and divided. Gallbladder removed from the liver bed using hook electrocautery. Hemostasis confirmed. Specimen placed in EndoCatch bag and removed through the umbilical port with mild fascial extension. Gallbladder fossa irrigated with 500 mL of warm saline, fully aspirated.

A 19 Fr Blake drain was placed in the gallbladder fossa given the pericholecystic abscess and brought out through the right anterior axillary 5 mm port site. Fascia at the umbilicus closed with 0 Vicryl using a Carter-Thomason device. Skin closed with 4-0 Monocryl subcuticular and Dermabond.

SPECIMENS:
- Gallbladder with stones, sent to pathology with indication: rule out gangrenous cholecystitis, evaluate margins, and r/o incidental gallbladder carcinoma.

ESTIMATED BLOOD LOSS: 75 mL
URINE OUTPUT: 220 mL
IV FLUIDS: 1.6 L lactated Ringer's
COMPLICATIONS: None

DISPOSITION:
Patient extubated in OR, transferred to PACU in stable condition. Plan: 23-hour observation on the surgical floor, advance diet as tolerated, IV ketorolac 15 mg q6h x 24h then oral oxycodone 5 mg q6h PRN, continue IV cefazolin 2 g q8h x 24h then off antibiotics if afebrile and WBC trending down. Blake drain to bulb suction, output check at 0700 and 1900. Path follow-up in clinic in 2 weeks.