Surgical Report

Surgical Report. Date of Report: 1 November 2024 Patient Name: John Smith Date of Birth: 12/03/1960 Medical Record Number: 1234567 Surgeon: Dr. Emily Carter Assistant(s): Dr. David Lee, Dr. Sarah Jones Anesthesiologist: Dr. Michael Brown Date of Surgery: 30 October 2024 Time of Surgery: 09:00 - 12:00 Procedure Performed: Laparoscopic Cholecystectomy Indications for Surgery: Symptomatic gallstones, recurrent biliary colic. Anesthesia: General anesthesia Estimated Blood Loss: 100 mL Fluids: 1500 mL Lactated Ringer's solution Drains: None Specimens: Gallbladder sent for pathology Complications: None Findings: Gallstones present in gallbladder. No evidence of choledocholithiasis. Description of Procedure: The patient was placed in a supine position. A 1 cm incision was made at the umbilicus, and a pneumoperitoneum was established. Three additional trocars were placed. The gallbladder was dissected free from the liver bed. The cystic duct and artery were clipped and divided. The gallbladder was removed. The abdomen was inspected for bleeding. The trocars were removed, and the incisions were closed. Postoperative Plan: Patient to be monitored in the recovery room. Pain management with IV analgesics. Diet as tolerated. Discharge home with oral pain medication and follow-up appointment in two weeks. Condition on Discharge from OR: Stable, awake, and breathing spontaneously.