AI Scribe for General Surgeons

OPERATIVE REPORT

PATIENT: 52-year-old female
DATE OF SURGERY: [Date]
SURGEON: [Surgeon Name], MD
ASSISTANT: [Assistant Name], MD
ANESTHESIA: General endotracheal anesthesia

PRE-OPERATIVE DIAGNOSIS:
Acute cholecystitis with cholelithiasis

POST-OPERATIVE DIAGNOSIS:
Acute cholecystitis with cholelithiasis, gangrenous gallbladder

PROCEDURE PERFORMED:
Laparoscopic cholecystectomy converted to open cholecystectomy

INDICATIONS:
52-year-old female presenting with 24 hours of right upper quadrant pain, fever to 101.5°F, and positive Murphy's sign. Ultrasound demonstrated gallbladder wall thickening, pericholecystic fluid, and multiple stones. Patient consented for cholecystectomy. Risks including bleeding, infection, bile duct injury, and need for conversion to open discussed.

FINDINGS:
- Severely inflamed, gangrenous gallbladder with pericholecystic abscess
- Dense adhesions to omentum and duodenum
- No bile duct injury identified
- Normal liver appearance

PROCEDURE:
Patient was brought to the operating room and placed supine on the table. General anesthesia was induced. Abdomen was prepped and draped in sterile fashion.

Initial laparoscopic approach: Pneumoperitoneum established via Veress needle, 12mm umbilical trocar placed under direct vision. Three additional 5mm trocars placed in standard positions. Laparoscopic examination revealed severely inflamed gallbladder with dense adhesions.

Due to severe inflammation and inability to safely identify anatomy laparoscopically, decision made to convert to open approach. Right subcostal incision made, carried through subcutaneous tissue and fascia. Gallbladder identified and dissected free from liver bed.

Calot's triangle carefully dissected to identify cystic duct and cystic artery. Cystic artery ligated and divided. Cystic duct identified, clipped proximally and distally, and divided. Intraoperative cholangiogram not performed given inflammation.

Gallbladder dissected from liver bed using electrocautery. Hemostasis achieved. Liver bed irrigated. Jackson-Pratt drain placed in Morrison's pouch and brought out through separate stab incision.

Fascia closed with running #1 PDS. Subcutaneous tissue irrigated. Skin closed with 4-0 Monocryl subcuticular.

SPECIMENS:
Gallbladder with stones to pathology

ESTIMATED BLOOD LOSS: 150 mL

COMPLICATIONS: None

DISPOSITION:
Patient tolerated procedure well and was extubated and transferred to PACU in stable condition. Post-operative orders written. Will follow for drain output and diet advancement.