Duration
Quality
Severity
Location
Timing
Modifying


There is one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. Extensive review of prior extemal notes from each unique source was performed. Extensive review of the results of each unique test was performed. Decision making involving ordering of each unique test was performed. Decision making regarding procedures with patient was performed. If applicable, discussion regarding procedure risk factors was performed. All patients have a corresponding same sex chaperone present during the entire encounter.


May discharge from surgical perspective
Instructions:
-May shower. No jacuzzi or baths for 1 week.
-May clean wound with isopropyl alcohol.
-May have normal oral intake.
-May use acetaminophen or NSAIDS for pain. Avoid narcotics.
-Must ambulate.
-No heavy lifting over 50 lb for 2 weeks.
-408 358 4747 for follow up call / Dr. A. Bastidas


-Laparoscopic cholecystectomy possible open.
-Risks, benefits, options discussed and understood.
-Risks includes but not limited to bleeding, infection, common bile duct injury, hepatic duct injury, bowel injury, bleeding, abscess formation, adhesions, cystic duct leak, intra-abdominal abscess, conversion to open, infection, death, and other intra-abdominal pathologies. Long term complications include but not limited to bowel obstruction, fistulas, chronic pain, chronic numbness and reoccurrence of the gallstone.
-Risks of anesthesia include but not limited to myocardial infarct, pulmonary embolism, stroke, and death were explained to the patient.
-Despite above, patient opted for surgical intervention. Informed face to face consent was obtained and surgery was scheduled.

There is one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. Extensive review of prior extemal notes from each unique source was performed. Extensive review of the results of each unique test was performed. Decision making involving ordering of each unique test was performed. Decision making regarding procedures with patient was performed. If applicable, discussion regarding procedure risk factors was performed. All patients have a corresponding same sex chaperone present during the entire encounter.


-Laparoscopic appendectomy possible open -Risks, benefits, options discussed and understood.
-Risks includes but not limited to bleeding, infection, organ / bowel injury, bleeding, abscess formation, adhesions, re-operation, intra-abdominal abscess, conversion to open, infection, death, and other intra-abdominal pathologies. Long term complications include but not limited to bowel obstruction, fistulas, chronic pain, chronic numbness and stump appendicitis.
-Risks of anesthesia include but not limited to myocardial infarct, pulmonary embolism, stroke, and death were explained to the patient.
-Despite above, patient opted for surgical intervention. Informed face to face consent was obtained and surgery was scheduled.

There is one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. Extensive review of prior extemal notes from each unique source was performed. Extensive review of the results of each unique test was performed. Decision making involving ordering of each unique test was performed. Decision making regarding procedures with patient was performed. If applicable, discussion regarding procedure risk factors was performed. All patients have a corresponding same sex chaperone present during the entire encounter.


Appendectomy

Operative Indication:
This is a *** with right lower quadrant pain, nausea, occasional vomiting, and on workup was found to have acute appendicitis. Computed tomography of abdomen and pelvis and history and physical exam was consistent with diagnosis. Surgery was indicated, Options presented to the patient include open surgery, IV antibiotics only, or no intervention at all. Acute complications of the surgery were explained to the patient. This includes but not limited to bowel injury, solid organ injury, bleeding, abscess formation, enterocutaneous fistulas, infection, re-operation, conversion to open, and other intra-abdominal pathologies. Long term complications include but not limited to enterocutaneous fistulas, bowel obstruction, and hernia formation. Risks of anesthesia include but not limited to myocardial infarct, pulmonary embolism, stroke, and death were explained to the patient. Patient opted for surgical intervention despite possible complications. Informed face to face consent was obtained.

Operative Details:
The patient was placed on the operating table in the supine position. General anesthesia was induced and patient was intubated without complication. IV antibiotics was initiated and given within one hour of incision. Surgical pause was commenced. Sequential compression devices were placed on bilateral lower extremities. Foley was placed in easily with clear urine extracted. The abdomen was prepped and draped in the usual sterile fashion. 2 ml of local anesthesia was injected below the umbilicus. A 7 mm incision was made with an 11 blade. The fascia was elevated and the 12 mm trocar inserted under direct vision in a Visiport fashion. Abdomen was insufflated to 15 mmHg with CO2. Patient tolerated insufflation well. The 5 mm zero degree laparoscope was inserted and the abdomen inspected. An exploratory laparoscopy was performed looking for pathology and injuries. No injuries from the initial trocar placement were noted. Scope was then switched to a 5 mm 30 degree scope. Turbid fluid was noted in the right lower quadrant. Under direct visualization, two 5 mm trocars were inserted in the right and left lower quadrants just lateral to the rectus muscle. Care was taken to avoid injury to the bladder or inferior epigastric vessels. The table was placed in Trendelenburg position with the left flank down. Using atraumatic graspers, the omentum was gently moved to the left flank. The taenia coli was identified and followed inferiorly until the cecum was identified. The terminal ileum was identified and followed to the cecum. Peri-ileal fat pad was identified and grasped via an atraumatic grasper and retracted anteriorly and toward the left flank.

Significant adhesions were found secondary to the appendiceal inflammation. The appendix was not seen. Dissection, enterolysis, and lysis of adhesion was performed until the omentum and adhesions were dissected away allowing the appendix to be identified. It was then grasped and elevated. It was noted to be inflamed.

A window was developed in the mesoappendix at a point between the base of the appendix and the cecum. An Endo GIA 45 x 3.5/2.5/2.0 was then used to divide and staple the base of the appendix. It was reloaded with Endo GIA 45 x 3.5/2.5/2.0 and the mesoappendix similarly divided. The appendix was withdrawn into the 12 mm trocar via an endoscopic retrieval bag and removed. The appendiceal stump was irrigated and hemostasis was assured with Endoclips placed on the mesoappendix and appendiceal stump. Another exploration was performed and all fluid was suctioned. The right upper quadrant and pelvis was inspected for purulent fluid. Under direct vision, the 12 mm port was closed with an Endoclose loaded with O - vicryl. All trocars were removed under direct vision. No bleeding was noted at the trocar sites. The laparoscope was withdrawn and the abdomen was allowed to collapse. The skin was closed with 4-O monocryl as a subcuticular suture. Dermabond were placed on all incisions. The patient tolerated the procedure well and was taken to the postanesthesia care unit in satisfactory condition. All instrument, sponge, and needle counts were correct. Good hemostasis was achieved throughout the case. Surgical debriefing performed.


Cholecystectomy

Operative Indication:
This is a *** with right upper quadrant pain, nausea, occasional vomiting, and on workup was found to have cholecystitis secondary to cholelithiasis with a normal common duct. Ultrasound and history and physical exam was consistent with diagnosis. Surgery was indicated. Options presented to the patient include open surgery, IV antibiotics only, or no intervention at all. Acute complications of the surgery were explained to the patient. This includes but not limited to common bile duct injury, hepatic duct injury, bowel injury, bleeding, abscess formation, adhesions, cystic duct leak, intra-abdominal abscess, conversion to open, infection, death, and other intra-abdominal pathologies.. Long term complications include but not limited to bowel obstruction, chronic pain, chronic numbness and reoccurrence of the gallstone. Risks of anesthesia include but not limited to myocardial infarct, pulmonary embolism, stroke, and death were explained to the patient. Patient opted for surgical intervention despite possible complications. Informed face to face consent was obtained.

Operative Details
The patient was placed on the operating table in the supine position. General anesthesia was induced and patient was intubated without complication. IV antibiotics was initiated and given within one hour of incision. Surgical pause was commenced. Sequential compression devices were placed on bilateral lower extremities. Foam was placed under all pressure points. The abdomen was prepped and draped in the usual sterile fashion. 2 ml of local anesthesia was injected below the umbilicus. A 3 mm incision was made with an 11 blade. The fascia was elevated and the 5 mm port was inserted under direct vision in a Visiport fashion. Abdomen was insufflated to 15 mmHg with CO2. Patient tolerated insufflation well. Vital signs were stable with 100% saturation. The 5 mm zero degree laparoscope was inserted and the abdomen inspected. An exploratory laparoscopy was performed looking for pathology and injuries. No injuries from the initial trocar placement were noted. Scope was then switched to a 5 mm 30 degree scope. Under direct visualization, a 12 mm trocar was placed in the epigastrium and a 5 mm trocar was inserted in the right flank. Care was taken to avoid injury to the bowel and liver. The table was placed in reverse Trendelenburg position with the left flank down. Laparoscopic enterolysis performed to expose the gallbladder which was aspirated for easier grasping. The dome of the gallbladder was grasped with an atraumatic grasper passed through the right lateral port and using the other atraumatic grasper, a 0-silk suture secured the fundus in a figure of 8 fashion. An intracorporal knot tie was done and an unloaded Endoclose was placed through the right upper quadrant to secure the suture, pull through to the skin surface, and secured with a Kelly clamp. This pulls the gallbladder in a cephalad direction. The infundibulum was then grasped with the traumatic grasper and retracted laterally. This maneuver exposed Calot's triangle. The peritoneum overlaying the gallbladder infundibulum was incised and the cystic duct and cystic artery identified and circumferentially dissected. Critical view of safety was obtained via double view and then time out initiated. The cystic duct and cystic artery were then doubly clipped proximally and distally and then divided close to the gallbladder. Weck Hem-O-Lok clips were used. The gallbladder was then dissected from its peritoneal attachments and liver bed by electrocutery. Hemostasis was checked and the gallbladder and contained stones were removed using an endoscopic retrieval bag placed through the epigastric port. The gallbladder was passed off the table as a specimen. The gallbladder fossa was copiously irigated with saline and hemostasis was obtained via electrocutery. There was no evidence of bleeding of the gallbladder fossa or cystic artery or leakage of the bile from the cystic duct stump. The epigastric port was removed under direct vision. An Endoclose loaded with a 0-vicryl was used to close the port site. No bleeding was noted. The 5 mm trocars at the right flank and umbilicus were inspected and there was good hemostasis. Exploratory laparoscopy performed did not find any iatrogenic injuries. The laparoscope was removed and both trocars were set to vent the CO2 from the abdomen entirely. Trocars were then removed. The skin was closed with 4-0 monocryl as a subcuticular suture in a running fashion. Dermabond were placed on all incisions. The patient tolerated the procedure well and was taken to the postanesthesia care unit in satisfactory condition. Good hemostasis was achieved throughout the case. All instrument, sponge, and needle counts were correct.