Postoperative Diagnosis: Acute cholecystitis with partially gangrenous gallbladder

Operation: Laparoscopic converted to open cholecystectomy

Anesthesia: General
Estimated Blood Loss: 150 cc
Urine Output: 100 cc
Intravenous Fluids: 2500 cc of lactated Ringer's
Complications: None

Findings: A partially gangrenous but mostly inflamed gallbladder with up to 1 cm thick gallbladder wall and multiple (greater than 50-100) small stones, each measuring approximately 2-4 mm

Description of Procedure: The patient was brought into the OR and placed in the supine position on the operating table. After successful endotracheal intubation, general anesthesia was safely achieved. Her entire abdomen was prepped with Betadine and draped in a sterile fashion. A 2.5-cm supraumbilical transverse incision was made for placement of a Verres needle to achieve pneumoperitoneum and the intra-abdominal cavity was insufflated with CO2 with difficulty. After the fascia on each side of the midline was secured with stay sutures, a knife blade was used to open the fascia and the 10-mm trocar was placed at this site. Upon insertion of the laparoscopic camera, no bowel injury was detected. A 10-mm trocar was then placed in the epigastric position at the midline. Two 5-mm ports were placed in the right upper quadrant, one around the nipple line just below the costal margin and the other around the anterior axillary line again below the costal margin. Through one of the 5-mm ports, an endoscopic needle attached to a 60-cc syringe was inserted in order to aspirate the content within the lumen of the gallbladder, which appeared to be extremely inflamed with what appeared to be a very thick peritoneal layer around the gallbladder.

Further dissection was made with a dissector introduced through the epigastric port. When the dissection was carried out down to the level of the gallbladder neck/cystic duct junction, the inflammation of the tissue around this region was so severe that it precluded a safe dissection of this area. The operation was therefore converted from laparoscopic to open cholecystectomy.

After the instruments and trocars, as well as the camera, were withdrawn from the incision sites, a skin incision was made between the epigastric site and the superior right upper quadrant 5-mm port site. The peritoneum was safely entered through this right subcostal incision. A Michotte retractor was placed cranially in order to retract the superior part of the operative field. Prior to opening the subcostal incision, the umbilical port site was closed at the fascial layer using a figure-of-eight suture. With the Michotte retractor in place, the superior portion of the wound was retracted open and several Mikulicz pads were placed within the abdomen to push the small bowel, colon, and stomach away from the operative field. A Kelly clamp was then placed over the fundus of the gallbladder and the peritoneum was scored with electrocautery. The gallbladder was then dissected off of the liver bed using electrocautery from the fundus down toward the neck. Portions of the peritoneal layer were approximately 1-cm thick. Several neovascularizations were noted within this thickened, inflammatory layer of tissue. Hemostasis was achieved using electrocautery. Several larger vessels from the neovascularization were ligated off with suture ties. Much of the gallbladder was shelled off of this inflammatory layer on the liver bed. The cystic artery was identified and ligated and divided between sutures. The cystic duct was also identified. The cystic duct/gallbladder neck junction was clearly identified in a retrograde fashion. The bottom of the gallbladder neck was clamped with a right-angle clamp, and the cystic duct/gallbladder neck junction was ligated with 2-0 silk tie. An additional 2-0 silk tie was placed to reinforce the ligature. The gallbladder was then resected and opened on the back table and sent to pathology. After successful resection of the gallbladder, the liver bed was inspected for any site of hemorrhage. The operative field was irrigated with antibiotic-soaked solution. A JP drain was then placed within the liver bed and brought out through the inferior right upper quadrant trocar site and secured to the skin with a suture.

After adequate hemostasis was achieved and confirmed, the irrigation fluid was aspirated from the abdominal cavity and the surgical wound was closed using PDS sutures. The skin was approximated using a skin stapler. All of the wounds were dressed with sterile gauze and secured with Tegaderm dressing. The patient tolerated the procedure well and there were no complications. The patient was extubated at the end of the case. All sponge and instrument counts were correct at the end of the case.

OUTPATIENT OFFICE ENCOUNTER

Bernard Collins is a 75-year-old male who has a long history of trouble urinating, along with frequent urinary tract infections. One month ago, an IVP done on February 2, 2010 showed a distended urinary bladder with a large postvoid residual. His symptoms include hesitancy and a decrease in the strength and force of his urinary stream. Physical exam reveals the prostate to be smooth, benign, and approximately 50 g in weight. We will discuss treatment options with the patient, including a TURP, when he returns in 1 week for follow-up.

DISCUSSION problemS:

1. After reviewing the Operative Report, provide the following in your post.

A. Please make a short summary of the above case. What procedure was intended? Why did it have to be converted? What were the abnormal findings? Be sure to describe any medical terms used in your response. 

B. Reviewing the operative report, identify some key diagnosis and organs investigated during the procedure. 

2. Reviewing the outpatient encounter Benard Collins, accomplish the following and report in your findings and comments in your post.

A. Go to Learn About a Test in the A.D.A.M. multimedia encyclopedia. Read all the information under Benign prostatic hypertrophy (hyperplasia) and look at the four images. View the video entitled Enlarged prostate gland. Look at Digital rectal exam in Clinical Illustrations (outside the encyclopedia on the ADAM home page).

B. After studying the material, summarize or paraphrase any information that you use in response to the discussion problems this week. Be sure and cite your source appropriately. Do not copy and paste.

C. describe to Bernard in a way that he can understand what has happened to his prostate gland as a result of aging.

3. General problems:

A. Describe the primary functions performed by digestive and urinary systems.

B. What are the structures of the digestive system?

C. What are the structures of the urinary system?