PREOPERATIVE DIAGNOSES:
1. Bile leak.
2. Status post cholecystectomy.

POSTOPERATIVE DIAGNOSES:
1. Bile leak.
2. Status post cholecystectomy.
3. Status post stent placement.
4. Normal pancreatic duct.

OPERATION PERFORMED: ERCP with stent placement.

ANESTHESIA: Monitored anesthesia care and oxygen by nasal cannula.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic woman who had a laparoscopic cholecystectomy approximately nine days ago. This was complicated by a bile leak, and she is now undergoing therapeutic ERCP to place a stent.

INSTRUMENT: Olympus JF-140.

DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was turned in the prone position and sedated. The duodenoscope was introduced through the bite block into the oropharynx and blindly advanced into the esophagus. The scope was passed through normal-appearing esophagus to the stomach. The gastric pool was aspirated. In the gastric antrum, there was a large collection of food material. This could not be aspirated. The scope was able to be manipulated past this into the distal antrum. The pylorus was identified and appeared normal. The duodenum was intubated, and the scope was passed through the second portion of the duodenum.

Bile flowed freely from a normal-appearing papilla of Vater. This was cannulated. Initial cannulation opacified the pancreatic duct. This was normal. It traveled in a somewhat more cephalad direction than usual. The common bile duct was then effectively cannulated. A bile leak was identified, but the site of leakage could not be seen.

With repeated manipulation of the cannula and attempts to pass the guidewire, we eventually obtained a deep cannulation. It appeared that her distal common bile duct moved in a U or J shape, making it more difficult to pass the guidewire. However, once deep cannulation was obtained, the wire was easily passed into the proximal ducts. The cannula was withdrawn as contrast was injected. No filling defects were identified. A 7 French, 7 cm straight stent was then passed over the guidewire. The proximal end of the stent reached the level of the surgical clips. The stent pusher and guidewire were withdrawn. The stent was placed in excellent position. The scope was withdrawn. The stomach was carefully evaluated as the scope was withdrawn. No additional abnormalities were seen. The patient tolerated the procedure well.

COMPLICATIONS: None at this time.

SPECIMENS: None.

RECOMMENDATIONS:
1. Follow laboratory studies.
2. Check ultrasound and have radiologist aspirate residual fluid in the a.m.
3. Repeat ERCP or EGD in eight weeks to remove the stent.

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PROCEDURES PERFORMED:
1.  Esophagogastroduodenoscopy (EGD).
2.  Gastric decompression.

PHYSICIAN:  John Doe, MD

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old woman with well-known upper GI/gastroduodenal Crohn disease, who has had multiple surgeries and has had upper abdominal pain and vomiting. The patient had an EGD by Dr. Jane Doe six months ago, which was reportedly unremarkable in terms of any obstruction with her gastrojejunostomy; although, as usual, the patient was obstructed through her native pylorus.

The procedure, its risks, benefits, and alternatives were explained to the patient in the presence of the nurse, and the patient was consented to proceed. The patient had continuous pulse oximetry and intermittent blood pressure monitoring throughout the procedure.

PREMEDICATION:  Fentanyl 75 mcg and Versed 4 mg.

DESCRIPTION OF PROCEDURE:  After adequate premedication, the Olympus GIF-160 endoscope was inserted atraumatically into the esophagus and advanced under direct vision. The esophagus was normal in its entirety. The stomach was next sighted, and it was easily and symmetrically inflatable. The gastrojejunostomy was noted on the posterior wall of the fundus. The antrum and pylorus were deformed, and the duodenal bulb was its usual closed off self. Upon entering the gastrojejunostomy with the scope, a total of 400 mL was suctioned out of the afferent limb and stomach. The afferent limb was unremarkable, and the previously noted strictures and ulcerations had all been dilated and stayed dilated. Minimal ulceration was noted at the gastrojejunostomy itself, and inside the gastrojejunostomy with the two ends coming together, no significant stricture was noted. The endoscope was then withdrawn and the procedure terminated. The patient tolerated it well.

IMPRESSION:
1.  Gastrojejunostomy anastomotic superficial ulceration.
2.  Afferent limb syndrome with perforation still in the afferent limb, 400 mL was suctioned out of this.

RECOMMENDATIONS:
1.  We are going to ask the patient to lean forward and to the left when she feels nauseous while she is vertical to try to empty the afferent limb.
2.  We would like to avoid surgery if we could.

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DIAGNOSES:
1.  Displaced gastrostomy tube.
2.  Traumatic brain injury.

PROCEDURE PERFORMED:  Esophagogastroduodenoscopy (EGD) with replacement of gastrostomy tube.

SURGEON:  John Doe, MD

ANESTHESIA:  Monitored anesthesia care.

INDICATIONS FOR PROCEDURE:  This is a (XX)-year-old African-American male who suffered a severe brain injury in a car crash. Subsequently, he has required feedings via gastrostomy due to poor swallowing. Gastrostomy tube was noted to have a leak around it, and an attempt to replace the tube directly met resistance and inability to pass a new gastrostomy tube.

ENDOSCOPY FINDINGS:  Normal-appearing pharynx and larynx with the gastroesophageal junction at 39 cm from the incisors. The gastric mucosa appeared normal through fundus, body, and antrum. The pylorus was wide open, and the duodenal bulb and descending duodenum appeared normal. In the distal body of the stomach, the gastrostomy site was noted to be open, and with initial pressure on the externally introduced gastrostomy tube, the edge of the tube was visible through the mucosal opening and was eventually introduced with external manipulation.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent and identification of the patient, the patient was transported to the operating room where monitoring and sedation was provided by the anesthesia service. With the patient supine, a video upper endoscope was introduced orally and advanced through the posterior pharynx into the esophagus and then through the esophagus into the stomach. The stomach was distended with air, and the endoscope advanced through the stomach and pylorus into duodenum and well into the descending duodenum. The endoscope was slowly withdrawn carefully inspecting mucosal surfaces. As the scope was withdrawn within the stomach, a retroflexed view was obtained and then the body of the stomach was visualized, and the previous gastrostomy site was evident and visualized by noting a mucosal opening. A 20 French MIC gastrostomy tube was placed within the external wound of the previous gastrostomy, and as this was introduced, the edge of the end of the gastrostomy tube was visible through the hole in the mucosa with the endoscope, but seemed to be slightly off to the side and so would not enter the stomach easily. Observing with the endoscope, the gastrostomy tube was then manipulated, and with some gentle pressure and twisting, the end of the gastrostomy tube entered the stomach. The balloon on the gastrostomy tube was then inflated and pulled back to have the flange or the balloon up against the mucosa. The external flange of the tube was then secured against the skin with the flange at approximately the 5 cm mark on the tube. Dressing was placed over the gastrostomy entry site. The gastroscope was then slowly withdrawn, carefully inspecting the mucosal surfaces of the esophagus as the scope was withdrawn. On complete withdrawal of the scope, the patient was then transported to the recovery room in stable condition.

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PREOPERATIVE DIAGNOSIS: Acute appendicitis.

POSTOPERATIVE DIAGNOSIS: Acute appendicitis, perforated.

OPERATION PERFORMED: Laparoscopic appendectomy.

SURGEON: John Doe, MD

ANESTHESIA: General.

DESCRIPTION OF OPERATION: After the patient had a Foley catheter inserted in the emergency room, she was brought to the operating room and given general anesthesia. The patient was then prepped and draped in the usual sterile fashion in the supine position with the mid abdomen exposed. The area of the umbilicus was infiltrated with 0.5% Marcaine. A vertical incision was made sharply through the skin and carried down through the midline fascia under direct vision. A suture was placed in the midline fascia and a blunt port placed intraabdominally. The abdomen was insufflated to 15 mmHg pressure with CO2 and a camera placed. Some adhesions to the anterior abdominal wall were carefully taken down after placing a 12 mm port inferior to the umbilicus. Once this was performed, a 5 mm port was placed in the right lower quadrant.

An obvious appendix, that was acutely infected and slightly perforated, was identified in the right lower quadrant. This was carefully freed from the surrounding tissue, and using a stapling device, the base of the appendix was carefully freed from the mesentery and stapled. The remaining mesentery was then stapled, and the appendix was placed into a bag. The area was then copiously irrigated with normal saline, and hemostasis was obtained with electrocautery. After adequate hemostasis, the rest of the abdomen was inspected, and no other areas were seen which were abnormal or bleeding.

Once this was performed, then the camera was placed into the lower 12 mm port site and the bag grasped with a sharp instrument and drawn up to the umbilicus. This was then carefully removed. Once the bag was removed, the abdomen was reinspected for hemostasis. After assuring hemostasis, the abdomen was deflated and the ports withdrawn.

The umbilical and lower midline port sites were closed in two layers. The small right lower quadrant port site was closed in a single layer. Steri-Strips, a clean dry pressure dressing, and Tegaderm were applied, and the patient was taken to the recovery room in satisfactory condition.

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Appendicitis.

POSTOPERATIVE DIAGNOSIS: Appendicitis.

PROCEDURE PERFORMED: Laparoscopic appendectomy.

SURGEON: John Doe, MD

ANESTHESIA: General.

COMPLICATIONS: None.

SPECIMENS: Appendix.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old lady with right lower quadrant pain and CT proven appendicitis. We recommended that she undergo appendectomy. The risks, benefits, and alternatives have been discussed with her, and she has consented for surgery.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating table. After undergoing anesthesia, her abdomen was prepped and draped in a standard sterile fashion using DuraPrep. A 5 mm Optiview trocar was placed in the supraumbilical position. The right upper quadrant and left lower quadrant trocars were placed. The appendix was grasped and elevated. It was indeed inflamed. We made a rent in the mesoappendix at the base of the cecum. A GIA stapler was used to staple the appendiceal artery. Another firing was used to transect the appendix and was placed in the bag and removed through the left lower quadrant trocar incision. We irrigated out and suctioned out the right lower quadrant, as well as some turbid fluid in the pelvis. Both staple lines were intact and hemostatic. The two working trocars were then removed. A 4-0 Monocryl was used to close the right upper quadrant and umbilical sites. On the left lower quadrant site, we used 0-Vicryl on the fascia and then a 4-0 Monocryl. Steri-Strips were applied. The patient was awakened and transferred to the PACU in satisfactory condition. The patient tolerated the procedure well.

General Surgery Sample Reports

DATE OF OPERATION: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Appendicitis.

POSTOPERATIVE DIAGNOSIS: Appendicitis.

PROCEDURE PERFORMED: Laparoscopic appendectomy.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal anesthesia, local 30 mL of 0.5% Marcaine with epinephrine.

FLUIDS: One liter of crystalloid.

ESTIMATED BLOOD LOSS: 5 mL.

COMPLICATIONS: None.

DISPOSITION: To the recovery room in stable condition.

INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who presents with an appendicolith, some mild right lower quadrant abdominal pain. Her appendix needs to be removed. Risks and benefits of surgical intervention were discussed with her. She states she understands these risks and is willing to proceed.

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating room table in a comfortable supine position. General endotracheal anesthesia was administered. Compression boots were placed on the patient. A Foley catheter was inserted. The patient was given Ancef 1 gram IV piggyback perioperatively. The patient’s abdomen was prepped and draped in a sterile fashion.

We began by anesthetizing skin and subcutaneous tissues supraumbilically. A small stab incision was made. A Veress needle was placed in the peritoneal cavity. The abdomen was insufflated to a pressure of 15 mmHg. Gained access through a trocar, and the camera, we were able to get in without difficulty. Two other stab incisions were then made after anesthetizing the skin and subcutaneous tissues. A 12 mm trocar was placed in the left lower quadrant. A 5 mm trocar was placed in the right upper quadrant. Through these, we were able to grasp and dissect out the appendix. We were able to free it up down to its base. We fired a 45 vascular Endo GIA across the appendix and then another firing across the mesoappendix, transecting the appendix and the mesoappendix. We then put the appendix in a bag, brought it out through the left lower quadrant fascial defect. There were a couple of small bleeding points that were cauterized.

We irrigated and suctioned the abdomen dry. We were satisfied with hemostasis. We removed the trocars under direct visualization, deflated the abdomen of as much CO2 gas as possible, and closed the incisions with 4-0 Vicryl subcuticular sutures. Benzoin, Steri-Strips, and a sterile dressing were applied. Sponge and instrument counts were correct. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: For evaluation and management of continuous diarrhea.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American male directly admitted with a diagnosis of nausea, vomiting, and dehydration. The patient states that he started having diarrhea, and had more than 10 stools a day. The patient states that his frequency of stool is fluctuating. He states that he did have a reddish stool. The patient’s son states that stool was the color of brown pudding earlier this morning. The patient did not have an appetite; apparently, appetite is improving. He is eating currently. He has not taken any new medication, has not done any recent traveling, has not taken any antibiotics. He denied any abdominal pain. Denied any odynophagia, dysphagia, chest pain, or shortness of breath. Denied any history of constipation. He has denied any GERD symptoms. The patient states that he has never had a colonoscopy.

PAST MEDICAL HISTORY: Significant for acute renal insufficiency, which has apparently progressed to acute renal failure, hypertension, diabetes, hypercholesterolemia, coronary artery disease, peripheral vascular disease, and bowel obstruction.

PAST SURGICAL HISTORY: Significant for vasectomy, CABG, tonsillectomy, and right knee arthroscopy.

SOCIAL HISTORY: The patient does have a history of smoking; he quit 20 years ago. Denies any alcohol usage.

FAMILY HISTORY: Negative for colon and stomach cancer.

ALLERGIES: No known allergies.

MEDICATIONS: Norvasc, Lipitor, glyburide, guaifenesin, Toprol, and Avandia.

PHYSICAL EXAMINATION: Vital Signs: Temperature 98.6 degrees, heart rate 90 beats per minute, respirations 20 breaths per minute, O2 saturation 94%, and blood pressure 112/58. Neurologic: The patient is alert and oriented x3. Heart: S1 and S2. Lungs: Clear to auscultation. Abdomen: Soft and nontender. Positive bowel sounds in all four quadrants. No organomegaly.

LABORATORY DATA: H&H on admission 10.6 and 31.8. Today, H&H is 10.6 and 30.8. White blood cell count 12.6, which is increasing; admitting was 10.4. Platelet count 246,000, bands 31. PT and INR four days back 15.6 and 1.26. Sodium 139 and potassium 2.9. The patient is on potassium protocol; last potassium was 3.2. BUN 60, creatinine 2.1 improving from BUN of 70 with creatinine of 6.2. LFTs two days ago; alkaline phosphatase 70, ALT 34, AST 30. Magnesium 1.8 on admission, amylase 102 with a lipase of 94. Urinalysis did indicate +1 bacteria and 2 to 5 hyaline casts with trace occult blood. Urine culture was unremarkable. Four days ago, fecal white blood cell count was negative. O&P was negative. CDT assay was negative.

DIAGNOSTIC DATA: Last chest x-ray yesterday did show well-ventilated lungs. Abdominal x-ray four days ago showed mild distension of the small and large bowel, possibly representing ileus, nonobstructive pattern. Renal ultrasound three days ago showed normal ultrasound. Renal nuclear medicine scan showed 50% function of the left and 50% function of the right.

IMPRESSION:
1.  Diarrhea with bandemia. Etiology is unknown, will be further worked up. Giardia is a possibility and diabetic diarrhea is also a possibility, or multiple other etiologies due to the patient never having a baseline colonoscopy.
2.  Nausea and vomiting, which has improved. The patient has not had any emesis today. He is eating, however, is having nausea off and on.
3.  Acute renal failure, which is improving.
4.  Hypertension.
5.  Diabetes.
6.  History of coronary artery disease with a coronary artery bypass grafting x3.
7.  History of hypercholesterolemia.
8.  Peripheral vascular disease.
9.  History of bowel obstruction.

PLAN:  Plan was reviewed with Dr. John Doe. Dr. John Doe did make rounds on the patient. Stool will be sent for culture, and the patient will have a total CDT of 3; 1 has already been done. Colonoscopy will be scheduled for Wednesday. Today, the patient will be on a clear liquid diet and will be n.p.o. after midnight. We will start 1 gallon of GoLYTELY today. Procedures have been explained to the patient. The patient is in agreement. If nausea or vomiting is not improved, EGD will need to be done to evaluate the patient for peptic ulcer disease or other etiologies. The patient will be started on Protonix 40 mg p.o. q.a.m. Further recommendations will be made pending lab results and colonoscopy findings.

Thanks for allowing us to participate in the care of your patient.

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DATE OF DISCHARGE: MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old widowed Hispanic female who was transferred from the nursing home because of vomiting of coffee-ground emesis. The patient had been previously hospitalized recently and evaluated and felt to have benign disease. At that time, she had similar vomiting of dark-colored material. An endoscopy, which included an esophagogastroduodenoscopy, found very little abnormalities.

After transfer to the rehabilitation nursing home, the patient had recurrent vomiting, required intravenous fluids. This subsided but then recurred, and she was brought back to the hospital. The patient has had a long history of atrophic-appearing pancreas and has been taking supplementary pancreatic enzymes. The patient has a long history of somatization with chronic fatigue extending over a period of many decades.

PAST MEDICAL AND SURGICAL HISTORY: Past history indicated status post hysterectomy many years ago, occasional urinary incontinence, hyperlipidemia, and osteoarthritis.

A metastatic workup, including CT scans of the abdomen and pelvis during the previous hospitalization, proved to be negative.

HOSPITAL COURSE: On admission, the patient showed marked dehydration and electrolyte imbalance and required supplementary fluids and electrolyte solutions. This was rectified and studies showed that there appeared to be a relatively high small bowel obstruction. The patient was placed on nasogastric suctioning. Material was not coffee ground but had a high content of bilious material. The patient’s blood count was somewhat low, and she required some blood transfusions; although, there was no profound anemia.

The patient was again seen in gastrointestinal consultation by Dr. John Doe. At this time, he performed a study using a colonoscope instead of a gastroscope and found an obstruction in the third portion of the duodenum. The abdominal ultrasound showed dilated small bowel loops and sludge in the gallbladder. In view of the obstruction, the patient was seen in surgical consultation. The surgeon felt that this most likely represented a malignancy. The patient was subjected to surgery and exploration, and it was found that indeed there was an obstructing lesion in the third portion of the duodenum. A palliative gastrojejunostomy was performed.

The patient’s postoperative status was somewhat precarious, but the patient gradually improved. The patient required hyperalimentation with supplements until her status and diet returned. At the time of discharge, the hyperalimentation was stopped. She was on soft diet plus Ensure Plus twice a day.

ALLERGIES: The patient is allergic to codeine.

DISCHARGE MEDICATIONS: The patient was discharged on metoprolol 25 mg b.i.d. to control blood pressure and heart rate, acetaminophen 650 mg q.6 hours p.r.n., Pepcid 20 mg b.i.d., and eye drops Trusopt 2% one drop in left eye b.i.d., Timoptic 0.5% one drop in the left eye b.i.d., and pilocarpine 2% two drops in the left eye q.i.d.

FINAL DIAGNOSES:
1.  Intestinal obstruction.
2.  Adenocarcinoma, third portion of duodenum.
3.  Dehydration and electrolyte imbalance.
4.  Sludge in gallbladder.

PROCEDURES PERFORMED:
1.  Exploratory laparotomy.
2.  Gastrojejunostomy.

OTHER PROCEDURES:
1.  Intravenous hyperalimentation.
2.  Blood transfusion.
3.  Abdominal ultrasound scan.
4.  Esophagogastroduodenoscopy and colonoscopy by the gastrointestinal service.

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DATE OF DISCHARGE: MM/DD/YYYY

ADMITTING DIAGNOSIS: Dysphagia.

DISCHARGE DIAGNOSIS: Dysphagia secondary to esophageal stricture. The patient is status post EGD and balloon dilatation of the esophageal stricture.

SUMMARY AND HOSPITAL COURSE: The patient is an (XX)-year-old lady with past medical history of dysphagia for many years and also history of hypertension, coronary artery disease, and also status post CABG surgery for three-vessel disease.

The patient presented to the hospital with complaint of progressively worsening dysphagia. The patient was admitted to the hospital for inpatient treatment of dysphagia and for GI consultation on EGD. The patient was admitted to the hospital and discharged to home on the same day. The patient was evaluated by the gastroenterology service and underwent EGD.

EGD showed esophageal stricture, possibly secondary to underlying gastroesophageal reflux disease. The patient had a balloon dilatation of the esophageal stricture and also EGD confirmed that the patient has erosive gastritis. At discharge, we changed the patient’s aspirin to Plavix, and we also put the patient on Aciphex 20 mg once a day. Otherwise, we continued all of her home medications at discharge.

PAST MEDICAL HISTORY: Otherwise negative other than coronary artery disease and hypertension. The patient does not have any history of diabetes or high cholesterol. She does not have any history of lung problem, asthma, or COPD. She does not have any history of heart failure, arrhythmia, or AFib. She does not have any history of any stroke, seizure problems, or thyroid problem. She does not have any history of kidney problem or liver problem.

PAST SURGICAL HISTORY: Status post CABG for three-vessel disease.

ALLERGIES: The patient is allergic to penicillin, tetanus, and sulfa medications.

HABITS: The patient denies any history of smoking, alcohol abuse, or drug abuse.

FAMILY MEDICAL HISTORY: Not significant.

HOME MEDICATIONS: The patient had been taking blood pressure medication; the patient does not remember the name of the medication. She also had been taking aspirin 81 mg once a day.

PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.2 degrees, respiratory rate 18, blood pressure 168/70, heart rate 72, and saturation 100% on room air. HEAD AND NECK: There is no JVD. There is no lymphadenopathy. Neck is supple. Thyroid is nonpalpable. HEART: S1 and S2 normal. S3 and S4 negative. Pulse rhythmic, palpable in four extremities. There is no carotid bruit. There is no cardiac murmur. LUNGS: Breath sounds are equal bilaterally. There is no wheezing. There are no rhonchi. There are no crackles. ABDOMEN: Soft, no mass, no tenderness, and no rigidity. EXTREMITIES: There is no peripheral edema. There is no calf tenderness. NEUROLOGIC: There are no focal neurologic deficits. Cranial nerves are intact.

LABORATORY DATA: White count is 4800, hemoglobin is 10, hematocrit is 30, and platelets 126,000. Sodium 152, potassium 4.2, chloride 108, bicarbonate 24, BUN is 40, creatinine is 1.4, and glucose is 96. Gastric biopsy result is pending. Chest x-ray is unremarkable, except for findings consistent with COPD.

The patient denied any complaints other than dysphagia. She denied any chest pain. She denied any shortness of breath. She denies any cough or sputum production. She denies any abdominal pain. She denies any change in color of stool. She denies any diarrhea or constipation. She denies any urinary problem.

IMPRESSION AND PLAN: Our impression is that the patient has dysphagia secondary to esophageal stricture. The patient had esophageal dilatation, successful, during EGD and discharged to home with Aciphex and also Plavix, and we stopped her aspirin at discharge. We recommended the patient to follow up with her primary care physician within a week. We also recommended her to come to the hospital or call her primary care physician if she develops worsening of the dysphagia, chest pain, palpitations, or shortness of breath.

We will also recommend the patient’s primary care physician to check patient sodium level and BUN and creatinine at the next visit. The patient’s elevated sodium, BUN, and creatinine are secondary to dehydration. The patient had esophageal dilatation. We expect the patient to start eating and drinking better. We expect her sodium, BUN, and creatinine to improve as the patient’s oral intake will improve.

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DATE OF DISCHARGE: MM/DD/YYYY

ADMITTING DIAGNOSES:
1.  Pancreatitis.
2.  Diabetes mellitus.
3.  Elevated blood pressure.

DISCHARGE DIAGNOSES:
1.  Pancreatitis.
2.  Diabetes mellitus.
3.  Elevated blood pressure.

PROCEDURES PERFORMED:  CT of the abdomen and pelvis.

CONSULTANTS:  John Doe, MD, Gastroenterology

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old man who has had epigastric pain for approximately one month. He was initially seen as an outpatient and given Nexium, which worked well until approximately two days prior to admission. On the morning of admission, he woke with severe pain. The patient’s wife called for an ambulance. It was noted that he had pancreatitis in the past with a pancreatic abscess. He stated his symptoms felt similar to that.

HOSPITAL COURSE:  In the emergency department, the patient was noted to have an elevated lipase, although his amylase was normal. A CT of the abdomen and pelvis was performed, which did not show any inflammation of the pancreas. There was an old fluid collection at the tail of the pancreas, which was felt to be a residual from his previous pancreatitis. He was admitted to the medical floor and made NPO for approximately 48 hours. His pain improved; although, he continued to take morphine 4 mg q.2 hours until approximately 24 hours prior to discharge.

It was noted that when he felt somewhat better, he would go outside and smoke, and he would smoke approximately one packet of cigarettes per day. We cautioned him that the cigarettes might actually be causing gastritis, which could perpetuate his pain. We also explained that we would not be able to discharge him home as long as he was taking morphine. As such, he discontinued his cigarettes and required only one dose of morphine in the following 24 hours. During his last 48 hours in the hospital, he was advanced from NPO status to a clear liquid diet to a soft diet. He tolerated this very well.

His diabetes was followed by Accu-Cheks q.6 hours, and then, when he ate, it was a.c. and nightly. His blood sugar varied from the mid 100 range to an above 200 range. He would follow up with this as an outpatient.

Upon arrival in the emergency department, his blood pressure was elevated at 162/90. He had no history of hypertension. His blood pressure subsequently returned to normal, as his pain was relieved, and it was felt that the elevated blood pressure was due to pain.

DISCHARGE PLANNING:

CONDITION:  Stable.

MEDICATIONS:  Glucophage, Protonix, Ultram, and Wellbutrin.

DIET:  Diabetic diet.

ACTIVITY:  As tolerated.

FOLLOWUP:  He was instructed to follow up with us in approximately two weeks.

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PREOPERATIVE DIAGNOSIS: Pancreatic cancer.

POSTOPERATIVE DIAGNOSIS: Pancreatic cancer.

OPERATION PERFORMED: Whipple surgery.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: About 350 mL.

COMPLICATIONS: None.

DESCRIPTION OF OPERATION: After informed consent, the patient was brought to the operating room and placed on the operating table in supine position. General endotracheal anesthesia was induced. The patient was prepped and draped in sterile fashion. A generous midline incision was made from C5 to below the umbilicus. Subcutaneous tissue was divided with the help of Bovie cautery. Peritoneum was entered. A Thompson retractor was placed. Chest wall was retracted upwards. A Kocher maneuver was performed after evaluating for metastatic lesions. No metastatic lesions were found anywhere in the peritoneal cavity. Frozen section was sent from the omental lymph node, which was negative. A couple of other lymph nodes from porta vein were sent, and all frozen were negative.

The duodenum was completely mobilized with the Kocher maneuver down to the ligament of Treitz. Colon was separated by dividing gastrocolic ligament and all the attachments. Short gastric vessels were divided. The vessels at the pylorus of the stomach were divided. At this point, middle colic vein was traced onto the superior mesenteric vein and to the portal vein. Dissection was done behind neck of the pancreas with the help of a Kelly clamp, which was very easy without any difficulty.

At this point, stomach was divided with GIA 75 on a green load and pylorus was retracted to the right side and rest of the stomach to the left side. Gallbladder was taken down with the help of the Bovie cautery. Cystic duct was clipped and divided. Gallbladder was removed. Common bile duct was dissected about 2 cm below the junction of the hepatic ducts. Common bile duct was dilated up to 1 cm in size. Hepatic artery was dissected up to the junction of gastroduodenal artery and hepatic artery. Gastroduodenal artery was ligated with 2-0 silk and suture ligated with 2-0 Prolene. It was retracted to the left side.

Portal vein was dissected. A complete tunnel was made under the pancreas, and a Penrose drain was placed behind the pancreas on top of portal vein. At this point, small bowel was divided approximately 20 cm from ligament of Treitz. Mesenteric attachments were divided with the help of LigaSure device. The jejunum was reflected to the right side of the ligament of Treitz. There were large vessels from the superior mesenteric vein to the head of the pancreas. Inferior pancreaticoduodenal vein was ligated with 2-0 silk. Several of the large branches were ligated. The pancreas was separated from the retroperitoneum with the help of LigaSure device, and the specimen was removed. Before removing the specimen, frozen section was sent from the pancreatic margin, which was negative.

After removing the specimen, irrigation was done and the staple part of the jejunum was oversewn with the help of 3-0 silk. It was brought up in a retrocolic fashion. Pancreaticojejunostomy was done in two layers, mucosa-to-mucosa, with 3-0 PDS and 5-0 PDS. Choledochojejunostomy was done with 5-0 PDS in a running fashion. Gastrojejunostomy was done in a handsewn method in a canal fashion with 3-0 silk and 3-0 PDS. Irrigation was done. Two JP drains were left; one was behind the gastrojejunostomy in front of pancreatic jejunostomy. One was left behind the choledochojejunostomy. The fascia was closed with loop PDS. Skin was closed with staples. Dressing was applied. The patient was extubated and taken to recovery in stable fashion. I was present for the entire procedure and all the counts were correct.

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PREOPERATIVE DIAGNOSIS:
Chronic cholecystitis.

POSTOPERATIVE DIAGNOSES:
1.  Chronic cholecystitis.
2.  Dense adhesions up to the gallbladder.

OPERATION PERFORMED:
1.  Laparoscopic cholecystectomy.
2.  Lysis of adhesions.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  100 mL.

INDICATION FOR OPERATION AND FINDINGS:  This is a (XX)-year-old female who had an extensive workup for abdominal pain. Ultrasound showed no stones. The patient’s HIDA scan showed a slightly below normal ejection fraction, and she had extensive workups. At the time of surgery, the patient had dense adhesions up to the gallbladder from the omentum that had to be taken down. This was quite difficult. They were deeply entrenched into the liver as well. We were able to free that up with some difficulty. The biliary tract anatomy was well identified. The cystic duct was seen down to its junction with the common bile duct. The cystic artery was isolated. All anatomy was well visualized.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. After adequate general endotracheal anesthesia, the abdomen was prepped and draped in a sterile fashion. The patient was given 1 gram of Rocephin intravenously. Next, 2 towel clamps were placed on either side of the umbilicus. An incision was made, and the Veress needle was introduced without any difficulty. The water drop test was positive. The needle was then attached to the CO2 insufflator and insufflated to a pressure of 15 mm. Next, the needle was removed and a 10 mm trocar was slowly and carefully introduced. The camera was placed with the introducer, and the abdomen was scanned. Three accessory ports were placed under direct visualization; one was placed in the subxiphoid region, one in the midclavicular line, and one in the midaxillary line. The patient was then placed in the reverse Trendelenburg position and rolled to the left.

The assistant then grasped the fundus of the gallbladder pushing above the dome of liver. There were dense adhesions up to the gallbladder and to the liver. These were taken down using blunt dissection and cautery. This took some time to get it freed up. We were able to finally get down to the area of the hepatoduodenal ligament. We had to cauterize the liver in several locations to control the bleeding. We were able then to dissect out the hepatoduodenal ligament. The cystic duct was identified and visualized down to its junction with the common bile duct. The entire biliary window was dissected out the cystic duct. The cystic artery was identified. There were no accessory bile ducts, and the anatomy was well visualized. Three clips were placed proximally on the cystic duct and one distally was divided. Two clips were placed proximally on the cystic artery and one distally was divided. The gallbladder was slowly and carefully taken off the liver bed using spatula cautery. Once it was free, the liver bed was checked. There was no bleeding or bile leak noted.

The gallbladder was then placed in the Ethicon pouch and brought out the umbilicus under direct visualization. The area was checked one final time. The right upper quadrant was irrigated and suctioned dry. Each of the ports was removed under direct visualization. The abdomen was desufflated. The fascia of the umbilicus was closed with #0 Vicryl suture. The skin incisions were closed with #4-0 Vicryl subcuticular sutures. It should be noted that each of the incisions and subcutaneous tissues were locally anesthetized with 0.5% Marcaine with epinephrine for a total of 24 mL. Dressings were placed, and the patient was taken to the recovery room in a satisfactory condition.

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