Louis J Sheehan Esquire 30046

SURGICAL PROCEDURE:

Laparoscopic cholecystectomy.

PREOP DIAGNOSIS:

Signs and symptoms included:

Digestive disturbances
Tenderness on pressure over gallbladder
Pain to back and right shoulder

Pathology: suffering from stones.

Diagnosis: Symptomatic non-acute cholelithiasis.

• Patients are fasted for approximately 8 hours before elective operations.

• Routine administration of intravenous antibiotics for prophylaxis against wound infections is not mandatory in uncomplicated cases of cholelithiases.

• Prior to induction of anesthesia, deep venous thrombosis prophylaxis should be utilized.

[Bib: A page 192.]

POSTOP DIAGNOSIS:

Symptomatic non-acute cholelithiasis.

Although major complications are rare, cardiopulmonary complications may occur as is the case in any major abdominal operation. Additionally, other rare possible complications include:

Bile duct injury
Bile leaks
Biliary stricture
Hemorrhage
Perforated bladder
Retained stones
Pancreatitis
Wound infections
Incisional hernia
Duodenal injury
Hepatic Artery injury
Damage to structure of Porta Hepatis
Atelectasis

[Bib: A page 189.]

Assuming there are no complications, postoperative care consists of:

• Clear liquids are resumed postoperatively and the patient progresses to a regular diet as tolerated.

• No activity or work restrictions are placed on the patient depending upon the degree of abdominal tenderness; the patient is encouraged to return to work within one week.

• Nausea and mild shoulder discomfort from diaphragmatic irritation may occur in the early postoperative period.

[Bib: A page 192.]
PREOP DIAGNOSTIC STUDIES:

History and physical.

Simple cholelithiasis resulting from obstruction of the infundibulum of the gallbladder or the cystic duct does not normally result in laboratory abnormalities. Serum bilirubin is usually normal unless there is a concomitant obstruction of the common bile duct.

Plain radiographs of the abdomen are rarely useful in diagnosing cholelithiasis.

Transcutaneous ultrasound of the upper right quadrant should be the diagnostic tool of choice in patients with suspected biliary pathology. Ultrasound is 95% sensitive and 98% specific in detecting gallstones and may demonstrate thickness of the gallbladder wall, pericholecystic fluid collections, choledococolothiasis, sludge, polyps, microcalcifications, and the diameter of the common bile duct. Additionally, the physician may also evaluate the right kidney, liver and pancreas. It should be noted that computed tomography (CT) is not as useful in evaluating biliary disease as is ultrasound.

[Bib: A page 183.]

TYPE OF ANESTHESIA:

The operation is performed under general anesthesia.

After induction of anesthesia, a urinary bladder catheter and a naso/orogastiric tube are generally placed to decompress these hollow organs

[Bib: A page 184.]


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SUTURE MATERIALS/CLOSING:
(DESCRIBE ABSORBABLE/NONABSORBABLE, MONOFILAMENT/MULTIFILAMENT)

• All port sites larger than 5 mm must be closed to reduce the risk of herniation.

• The incisions were anesthetized locally.
Bupivacaine with Epinephrine.

• The fascia of the umbilical incision was closed with large absorbable sutures.
0-Vicryl is a multifilament absorbable suture.

• The skin of the subxiphoid umbilical incisions was closed with subcuticular sutures.
4-0 Vicryl is a multifilament absorbable suture.

• Bandaids/medipore 2 2/3 inches were applied to each incision.

[PIC Sheet]

TIES

PERITONEUM:
FASCIA:
SUBCUTANEOUS:
SKIN/SUBCUTICULAR:
OTHER:

I am unaware that any ties were used.

ELECTROSURGICAL UNIT

TYPE: bovie pencil
MONOPOLAR/BIPOLAR: monopolar
SETTINGS: 25, sometimes done at 30
PLACEMENT OF DISPURSIVE PAD: leg/thigh
ESU TIP USED: coated blade

INSTRUMENT SET(S):

Complete gallbladder tray
Laparoscopic bin
Minor basin set
Camera tray
Scope warmer tray

[Bib: D page 77.]

SUPPLIES

BLADES: #11
PACKS: Laparoscopic Choly pack; C-Arm drape
DRESSINGS: Bandaids/medipore 2 2/3 inches

Basic pack
Towels
Basin set
Cleaning kit (defogger)
Padding for elbows and ankles
Sony paper for printing photographs
Dr. A. always uses compression stockings
Prep set
Gloves
Gown

[Bib: D page 77.]

DESCRIBE PREPPING PROCEDURE:

Dr. A. wanted the abdomen prepped in standard fashion with betadine applied 3 times. The betadine was applied from the midline-axilla down to (but not including) the pubic symphysis and down to the table at the sides.

[Bib: D page 76.]

MEDICATIONS/IRRIGATIONS:
(LIST MEDICATION AND ROUTE OF ADMINISTRATION)

.9% saline via hanger
H2O 1000 mL
.9% saline 1000 mL for injection
Syringe 10 cc luerlock
Syringe 20 cc luerlock
Syringe 30 cc luerlock
Leurlock plug m/f
A ½ inch needle
0.25% Bupivacaine with Epinephrine

[PIC Sheet.]
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SPECIAL EQUIPMENT:
(CATHETERS, DRAINS, PACKING)


• Two 5 mm ports
• Two 10 mm ports
• Three 5 mm ratcheted graspers
• One 5 mm scissor (Metz)
• One 5 mm hook cautery
• One 5 mm curved dissector
• One 10 mm claw grasper
• One entrapment sack
• One loop ligature
• Video cart
• C02 insufflator
• Slave monitor
• A seal
• Disposable clip appliers (one medium, one large)
• 2000 cc suction canister
• Foley catheter 18 Fr with urimeter kit
• Scope warmer
• Suction apparatus

[Bib: A page 185.]

POSITIONING

PATIENT POSITIONING:

Supine. Arm on armboard.

OR BED POSITION:

The table was initially placed in Trendelenburg between 5 and 10 degrees to facilitate the establishment of the C02-pneumoperitineum. Then the patient was positioned in a 30 to 40 degree Reverse Trendelenburg and was further rotated to the left by 15 – 20 degrees. These movements/repositionings allowed the colon and duodenum to fall away from the liver’s edge and the falciform ligament and the liver (both lobes) to be examined. The inferior margin of the liver was also more easily visualized so as to locate the gallbladder. In most surgeries the gallbladder is visible beyond the edge of the liver but, sometimes, the gallbladder can only be seen after adhesions are removed and/or after elevating the liver.

[Bib: B page 90.]

POSITIONING SUPPLIES AND EQUIPMENT:

Adjustable OR bed
Armboards
Footstool

[PIC Sheet]





DRAPPING PROCEDURE:

Squared off towels around the abdomen. Laparotomy drape /sheet with tape removed.

[Bib: D page 76.]

DESCRIBE SURGICAL PROCEDURE:
(IF AN ORGAN(S) WAS/WERE REMOVED, WHAT STRUCTURES WERE LIGATED TO REMOVE THE ORGAN(S)?)
(WHAT INSTRUMENTS WERE USED?)
(COUNTS?)

ANATOMY:

See attached drawings.

[Bib: E pages 12 – 39.]

COUNTS:

1. When all items open on backtable and before mayo set-up.
2. Closing 1: at closing of peritoneum/first layer of cavity.
3. Closing 2: at closure of fascia.
4. Closing 3: initiation of skin closure.

Port Placement - CO2-pneumoperitineum 10 mm Trocar

A CO2-pneumoperitineum was created to facilitate safe placement of trocars into the abdomen; 15 mmHg is a conventional benchmark. The CO2-pneumoperitineum can be created using either an open or closed technique. If hemodynamic compromise were to develop, the CO2-pneumoperitineum would be emptied until vital signs return to normal.

At the infraumbilical skin fold an incision of approximately 1.5 cm horizontally was made to place the CO2-pneumoperitineum port.

Next, the retroperitoneum posterior to the umbilicus and the pelvis were viewed to ensure there was no injury resulting form the trocar/sheath with a 10 mm laparoscope/camera. While there, the pelvic viscera, anterior surface of the intestines, omentum and stomach were visualized and no abnormalities were noted.

Two 5 mm Subcostal Ports

The surgeon next placed two 5mm subcostal ports in the upper right quadrant.

The first port was placed in the anterior-to middle axillary line between the 12th rib and the iliac crest inferior to the gallbladder fundus/liver edge.

The second 5 mm port was placed midway between he axillary sheath and the xiphoid process.

These two ports allowed the use of grasping forceps to retain/secure the gallbladder. The lateral grasping forceps were used to elevate the liver’s edge to clearly expose the fundus of the gallbladder. The dissecting forceps were then used to raise the most dependent portion of the fundus. The grasping forceps were then used to push laterally and cephaladly to roll up the entire right lobe of the liver so as to expose the porta hepatis and the gallbladder. Adhesions in this area are generally avascular and were lysed bluntly with dissecting forceps by slowly stripping them in the direction of the infundibulum; any vascular adhesions would be lysed with the hook cautery.

After the infundibulum was exposed, grasping forceps were placed through the midclavicular trocar for traction on the neck of the bladder.

The Second 10 mm Trocar

The last trocar was placed through a longitudinal incision in the midline of the epigastrium near the location of the gallbladder (the size of the left liver lobe can also influence placement). This trocar was angled to the right of the falciform ligament aiming toward the gallbladder.

Exposure

The fundus was now retracted superiorly to the infundibulum. The gallbladder was placed under tension and away from the common bile duct in the inferolateral direction. With the fundus and neck of the gallbladder under tension, a fine-tipped dissecting forcep was used to gently pull away the overlying fibroareolar structures from the gallbladder infundibulum and Hartmann’s pouch starting on the gallbladder and pulling the tissue toward the porta hepatis.



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Dissection

The peritoneum was lysed. The hepatocystic triangle (a.k.a. Calot’s triangle) was placed under tension and exposed by retracting the gallbladder infundibulum inferiorly and laterally while pushing the fundus superiorly and medially. Often there is a lymph node overlying the cystic artery which, if there, is removed; if so, electrical current is used to achieve hemostasis.

The infundibulum of the gallbladder was stretched superiorly and medially even as the fundus was pushed superiorly and laterally to expose the reverse of the hepatocystic triangle (the area between the cystic duct, the common hepatic duct, and the right lobe of the liver). It was critical to precisely locate the junction between the infundibulum and the origin of the cystic duct. The tip of the hooked-shaped cautery was used to probe and expose the duct. The cystic artery is often separated from the surrounding tissue now (but can be separated later depending upon the individual’s anatomy). The cystic duct was now dissected as it was anteriorly in the field.

Cholangiography

Some surgeons now perform a static or fluoroscopic cholangiography for evaluation of the stones at this juncture. (I did not see any of this.)

Cystic Duct

The Cystic duct was then doubly clipped near its junction with the common bile duct and then was divided. Care was taken to avoid injuring surrounding structures with the clips. Great care was taken to avoid clipping the common bile duct; if this were to prove to be too risky, a loop or suture would have been used instead of clips.

Cystic Artery

The infundibulum of the gallbladder was placed under tension and the cystic duct was bluntly dissected, then clipped proximally and distally and divided by sharp dissection.
Care was taken to not confuse the right hepatic artery with the cystic artery.

The ligations of the duct and cystic artery were examined to confirm that neither bile nor blood is leaking, that the clips are secure, and that the clips close the entire lumen without attaching any of the adjacent tissue. Irrigation and suctioning were used to remove debris. The grasping forceps in the midclavicular trocar were repositioned on the proximal end of the gallbladder at Hartman’s pouch. The infundibulum was retracted superiorly and laterally and also away from its hepatic bed. The tissues that tethered the neck of the gallbladder were inspected to ensure no other sizeable tubular structures were in this immediate area. The hepatic fossa was divided and coagulated (both small vessels and lymphatics were coagulated). On rare occasion, a blood vessel or small duct will require the placement of another clip.

Gallbladder Dissection

As necessary, any tears in the gallbladder wall may be clipped or looped to prevent stone leakage or additional bile leak.

As always (i) the hepatic fossa and porta hepatis were monitored for any blood and/or bile leakage, (ii) the clips were monitored for stability, and (iii) small bleeding points were coagulated with electrocautery, and (iv) the liver was examined for hemostasis. Further, irrigation assists with the visualization at this juncture.

The gallbladder was then separated with electrocautery. With the tissue connecting the gallbladder to the fossa placed under tension, the surgeon used electrocautery (typically the hook) set at 25 (sometimes 30) to divide and coagulate the tissue.

The dissection of the gallbladder continued from the infundibulum to the fundus with intermittent repositioning of the midclavicular grasping forceps proximal to the plane of dissection to allow maximal contraction until the gallbladder was attached only by a narrow and thin tissue.

Finally, the little remaining attachments to the gallbladder were lysed.

Removal

The laparoscope was transferred to the midepigastric port.

The gallbladder was removed via the umbilicus under direct visualization from the laparoscope. The umbilical port was used because there are no thick muscle layers at this point and there is only one fascial plane that must be crossed. Additionally, if an incision needs to be enlarged because of the size of the stones, extending the umbilical incision causes less postoperative pain than does extending any of the other incisions.

At Harrisburg, I have always seen the use of an entrapment bag. The grasper forceps were used to place the gallbladder into the entrapment sack. The gallbladder-containing entrapment sack was then withdrawn through the umbilical port. This left the neck of the gallbladder on the anterior abdominal wall and the distended fundus within the abdominal cavity.

If the gallbladder were to be enlarged due to stones or bile, a suction catheter could have been used for aspiration before the entrapment sack’s withdrawal. As an alternative, stone forceps could have been placed into the gallbladder to extract or crush overly large stones. Rarely, the incision must be enlarged to remove larger stones.

The gallbladder was a specimen.

[Bib: A pages 186 – 191, B pages 90 – 94, C pages 192 – 194.]




BIBLIOGRAPHY

A =
Laparoscopic Surgery, Principles and Procedures, 2nd Edition. Edited by D.B. Jones, J.S. Wu, and N.J. Soper. Pages 181 – 196 (2004).

B=
Laparoscopic Surgery of the Abdomen, B.V. MacFayden, Jr. as Senior Editor. Pages 87 – 99 (2004).

C=
Laparoscopic Surgery, by Cueto-Garcia, Jacobs and Gagner. Pages 191 – 195 (2003).

D=
Pocket Guide to the Operating Room, 2nd Edition. M.A. Goldman. Pages 74 – 79. (1996).

E=
Atlas of Minimally Invasive Surgery, by Jones (MD), Maithel (MD) and Schneider (MD). Pages 12 – 39 (2006).

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The holidays are over. Resolutions are wearing thin. It's a time of year when many people wonder if they have a drinking problem.

More than 30% of Americans engage in risky drinking at some point in their lives, according to the National Institute on Alcohol Abuse and Alcoholism. But there's no consensus on exactly what an "alcoholic" is. Even Alcoholics Anonymous relies on alcoholics to diagnose themselves.


Researchers have made up dozens of screening tests over the years. According to one developed for Johns Hopkins University Hospital years ago that still pops up on the Web, I'm "definitely an alcoholic" because I answered yes to at least three of 20 questions: I "crave a drink at a definite time of day" (evenings, mostly) and drink alone (sometimes) and drink to "escape from worries or troubles" (doesn't everyone who drinks?).

But Alcoholscreening.org3 says I'm "below the range usually associated with harmful drinking or alcoholism" since I have only a glass or two of wine when I drink.

The authoritative American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, separates alcohol abuse from alcohol dependence, based partly on the problems the drinking causes. You qualify for a diagnosis of "abuse" if you've done any one of these in the past year: drunk alcohol in hazardous situations, like driving; kept drinking despite social or interpersonal problems; had legal problems related to alcohol or failed to fulfill major obligations at work, school or home because of drinking.

You've moved on to "dependence" if you've done any three of these seven: drunk more or longer than you intended; been unable to cut down or stop; needed more alcohol to get the same affect; had withdrawal symptoms without it; spent more time drinking or recovering; neglected other activities or continued to drink despite psychological or physical problems.

Experts long believed that abuse progressed to dependence, which almost inevitably became chronic and relapsing -- but that was based on observing severely addicted people in treatment programs. Several large new surveys have shown that drinking patterns in the general population are much more varied, with milder forms of dependence. Some 43% of daily heavy drinkers don't fit into either DSM-IV category, according to one big national sample, even though they are setting themselves up for serious health and addiction problems.

Abuse vs. Dependence
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"Some people will abuse alcohol -- driving drunk, for example -- but they only drink heavily once a month. They can remain stable for a long time and not progress to dependence," says Mark L. Willenbring, director of the division of treatment and recovery research at the NIAAA. "And people can be dependent and not have abuse problems at all. They're successful students. They're good parents, good workers. They watch their weight. They go the gym. Then they go home and have four martinis or two bottles of wine. Are they alcoholics? You bet. And the goal is to get treatment for these folks, earlier, that is acceptable and attractive and effective."

To that end, some experts want the DSM-V -- the new edition now being compiled -- to combine abuse and dependence into a single "alcohol-use disorder" that ranges in severity, taking into account harmful drinking patterns and other symptoms. The aim is for simmering problems to be spotted sooner.

As one former treatment counselor says, "The conventional wisdom held that alcoholics had to hit bottom before they could get better. We'd like to raise that bottom so that people don't have to fall as far before they get help."
[Health]

Many heavy drinkers are very high-functioning -- until they can't function anymore. "Alcoholics can be high achievers in the short run, because they're driven and compulsive," says Charlie, a New York attorney who, like all AA members, wants to remain anonymous. Charlie was drinking about a fifth of Johnnie Walker most nights when it began to show. "I'd tell my secretary I was in a meeting with a client, but I'd be home and only starting to feel human by about noon. Then I'd try to do eight hours of work in four hours," he says. This went on for seven years, until he finally went into rehab. He's been sober now for 26 years.

Charlie says many heavy drinkers, especially those who grew up around alcoholics, set a private benchmark in their denial. "They say to themselves, 'As long as I'm not making a fool of myself in a bar, or drinking in the morning, or as long as I'm still showing up for work, then I'm not an alcoholic.'"

You know you've hit bottom, he adds, "when your behavior spirals downward faster than you can lower your standards."

Thinking You're Immune

Ruth, a nursing supervisor in Las Vegas, hid her quart-a-day whiskey habit from work for about five years -- "until my husband and my employer both invited me out of those positions at the same time," she says. "That got my attention."

Both of Ruth's parents died of alcohol-related illnesses, but she thought her medical training would protect her from getting seriously addicted. Doctors and clergy who drink heavily often have the notion that they are somehow immune to the problems they see in others, she observes, and affluent people can pay others to take care of them. "People with less money and less education often get the message faster," she says, now that she's been sober for 37 years.

NIAAA officials say that in recognizing a drinking problem, the label "alcoholic" is less important than harmful patterns of drinking, which they describe as drinking too much, too fast or too much, too often.

Too much, too fast means consuming more than four drinks in two hours for men, and more than three in two hours for women. That's a level that, on average, makes people legally drunk and impairs brain function. (A standard U.S. drink, by the way, is 12 oz. of beer, 5 oz. of wine or a 1.5 oz. shot of 80 proof spirits, according to government agencies.)

Even if you stay within those limits each day, you can be drinking too much, too often, if you have more than 14 drinks a week for men, and more than 7 for women. That's the kind of chronic use that raises the risks of a long list of health problems, including liver and cardiovascular disease, pancreatitis, dementia, depression and numerous cancers.

How those weekly drinks are distributed is also important. "If you drink seven drinks in two days, that's hazardous -- you're drunk two days a week," says Ting-Kai Li, the NIAAA's director. "If you drink two a day for seven days, that's not harmful. In fact, it may even be beneficial for some people, lowering their cardiovascular risk."

Individual responses to alcohol vary, of course, based on genetics, brain chemistry, metabolism and other factors. Your risk is already elevated if you have a family history of alcohol abuse, have health problems such as depression, take certain medications or you started drinking at an early age. "If you have a family history or other co-morbidity, then the general advice is, don't drink at all," says Dr. Li.

If you're worried that you may be drinking too much, you've already met a key criterion on some screening tests. (Like the old saying about mice in your house, if you think you have a problem, you probably do.)

Counting drinks very carefully to stay within the limit can be a sign of trouble too, says Ruth. "The glass keeps getting bigger and bigger or you forget to add the mixer." She suggests trying to go 30 or 60 days without drinking. "If it doesn't bother you, you're OK. But if you're desperate for that 30 days to end, or you can't make it, then get help." She suggests trying one of AA's public information meetings. "If you're not an alcoholic, you can't catch it from them," she says.

Your family doctor is another place to start. The NIAAA recently issued a guide for primary-care physicians (www.niaaa.nih.gov/guide4) to enlist their help in spotting alcohol problems. It starts with a single screening question: How many times in the last year have you had more than five drinks (four for women) in a day? If the answer is even once, doctors are advised to discuss the risks of harmful drinking with their patients, along with steps patients can take to cut back, including new medications that can help curb alcohol cravings.
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In Remission

The encouraging news from the NIAAA's recent research is that many people do cut down or quit on their own. "That's the real mind blower," says Dr. Willenbring. "Only about 15% of the people who develop alcohol dependence in their lifetime have the severe, relapsing form. Most people -- 72% -- have a single episode [of addiction] lasting on average three or four years and then they go into remission and stay there. A lot of them are abstaining." For many people, that spate of heavy drinking happens in college -- the peak years are 18 to 24, says Dr. Willenbring. "Then they mature out of it and get on with their lives."

For those who don't, alcoholism, however it's defined, is still a profound problem, and the third leading cause of preventable death in the U.S., after smoking and obesity. But being aware of your risks and cutting down now if you need to may prevent you from becoming one of those statistics.