Operative Report: Laparoscopic Appendectomy and Placement of Right Lower Quadrant Drain
OPERATIVE REPORT CASE 2
Patient Name: Benjamin EngelhartAge: 46DOB: 10/5/----Sex: M
ID Number: 112592
Date of Admission: 11/14/----
Date of Procedure: 11/14/----
Admitting Physician: Bernard Kester, MD
Surgeon: Bernard Kester, MD
Assistant: Jason Wagner, PA-C
Circulating Nurse: Jimmy Dale Jett, RN
Preoperative Diagnoses: Acute appendicitis
Postoperative Diagnoses: Perforated appendicitis
Operative Procedure:
1 Laparoscopic appendectomy
2 Placement of right lower quadrant drain
Anesthesia: General endotracheal tube anesthesia
Specimen removed: One necrotic appendix
IV Fluids: 1700 mL crystalloid
Estimated Blood Loss: 10 mL
Urine output: 300 mL
Complications: None
INDICATIONS: This gentleman is a 46-year-old Caucasian male with a 3 day history of abdominal pain. However, over the past 24 hours his pain has located to the right lower quadrant and caused a significant amount of anorexia. He presented to the Emergency Department where a CT scan of his abdomen and pelvis revealed acute appendicitis. Lab showed a WBC count of 13. The laparoscopic appendectomy procedure was explained to the patient along with the risks, benefits, and possible complications. Patient voiced his desire to proceed. Patient was started on pre op gentamicin.
DESCRIPTION OF PROCEDURE: The patient was identified x2 in the preoperative holding area. A final time out was held with the nursing service, anesthesia, and the surgical service during which the patient’s ID was confirmed and the surgical site was initialed. He was given perioperative antibiotics. He was taken back to the operating room and placed in the supine position. General ET anesthesia was induced. SED’s were placed on his lower extremities. The patient’s left arm was tucked at his side. A Foley catheter was placed. His abdomen was shaved, prepped with benzoin solution and draped in the usual standard fashion.
A small semicircular infraumbilical incision was made and carried down through the subcutaneous
Patient Name: Benjamin EngelhartAge: 46DOB: 10/5/----Sex: M
ID Number: 112592
Date of Admission: 11/14/----
Date of Procedure: 11/14/----
Admitting Physician: Bernard Kester, MD
Surgeon: Bernard Kester, MD
Assistant: Jason Wagner, PA-C
Circulating Nurse: Jimmy Dale Jett, RN
Preoperative Diagnoses: Acute appendicitis
Postoperative Diagnoses: Perforated appendicitis
Operative Procedure:
1 Laparoscopic appendectomy
2 Placement of right lower quadrant drain
Anesthesia: General endotracheal tube anesthesia
Specimen removed: One necrotic appendix
IV Fluids: 1700 mL crystalloid
Estimated Blood Loss: 10 mL
Urine output: 300 mL
Complications: None
INDICATIONS: This gentleman is a 46-year-old Caucasian male with a 3 day history of abdominal pain. However, over the past 24 hours his pain has located to the right lower quadrant and caused a significant amount of anorexia. He presented to the Emergency Department where a CT scan of his abdomen and pelvis revealed acute appendicitis. Lab showed a WBC count of 13. The laparoscopic appendectomy procedure was explained to the patient along with the risks, benefits, and possible complications. Patient voiced his desire to proceed. Patient was started on pre op gentamicin.
DESCRIPTION OF PROCEDURE: The patient was identified x2 in the preoperative holding area. A final time out was held with the nursing service, anesthesia, and the surgical service during which the patient’s ID was confirmed and the surgical site was initialed. He was given perioperative antibiotics. He was taken back to the operating room and placed in the supine position. General ET anesthesia was induced. SED’s were placed on his lower extremities. The patient’s left arm was tucked at his side. A Foley catheter was placed. His abdomen was shaved, prepped with benzoin solution and draped in the usual standard fashion.
A small semicircular infraumbilical incision was made and carried down through the subcutaneous