DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Primary refractory stage IIIB nodular sclerosing Hodgkin’s disease.
2. Liver failure.
POSTOPERATIVE DIAGNOSES:
1. Primary refractory stage IIIB nodular sclerosing Hodgkin’s disease.
2. Liver failure.
OPERATIONS PERFORMED:
1. Laparoscopic liver biopsy.
2. Evacuation of ascites.
SURGEON: John Doe, MD
ANESTHESIA: General via endotracheal tube.
SPECIMENS:
1. Liver biopsy x3.
2. Tru-Cut liver biopsy x2.
COMPLICATIONS: None.
DRAINS: None.
ESTIMATED BLOOD LOSS: 75 mL.
FINDINGS: Upon gaining entry into the peritoneal cavity, there was a fairly large amount of ascitic fluid, which was nonpurulent. Approximately 6 liters of ascites was evacuated. Examination of the liver showed it to be somewhat nodular, and upon performing the liver biopsies, it was quite dense and hard regarding the parenchymal tissue. No other abdominal pathology was noted.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who is status post bone marrow transplantation secondary to nodular sclerosing Hodgkin’s disease. The patient, during his hospital course, has now worsened and is presenting with signs of liver failure. Due to unknown etiology, they have requested a surgical consultation for a liver biopsy. The patient was seen at the bedside. All risks, benefits and alternatives of the procedure were described in detail to the patient per staff. The patient, along with his family, agreed to proceed. Operative consent has been signed and placed upon the chart. The patient’s anticoagulation due to his blood disorder has been aggressively reversed. Preoperative antibiotics have already been initiated per bone marrow protocol.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. General anesthesia was then induced. A Hasson cutdown technique was then utilized in a supraumbilical location. Upon gaining entry into the peritoneal cavity, a very large amount of ascitic fluid had to be siphoned free prior to placing a 5 mm trocar. Once we were able to place the 5 mm trocar, the patient’s abdomen was then insufflated with carbon dioxide to create a pneumoperitoneum to approximately a total of 15 mmHg. The patient did tolerate the insufflation well.
A 30 degree laparoscope was then inserted. Examination of the liver showed it to be nodular in appearance with a large amount of ascitic fluid, which was not purulent. Additional trocars were then placed, an 11 mm in the subxiphoid region and another 5 mm in the right upper quadrant. At this time, approximately 6 liters of ascitic fluid was then evacuated to gain entry to the liver parenchyma because it was submerged in all the ascites.
At this time, we then took a Tru-Cut core biopsy needle into liver parenchyma x2 and got adequate specimens. Once this was completed, we then took three liver biopsies with the use of laparoscopic scissors. Once these were taken, they were passed off the field and sent to pathology. Hemostasis was intact with the use of Bovie electrocautery at the liver edge. We also applied a piece of Surgicel within the liver biopsy sites. The liver bed was then reexamined and shown to be hemostatic. The trocars were removed under direct vision. No bleeding was noted at the trocar sites. The abdomen was allowed to collapse. The 5 mm trocar and laparoscope were then removed.
The fascia from the xiphoid along with the supraumbilical locations was closed with 2-0 Vicryl in figure-of-eight fashion. Skin incisions were closed with staples. The patient was then awoken from anesthesia and transported back to the bone marrow transplant unit in stable condition and extubated. All sponge, needle, and instrument counts were correct at the end of the case.
