*** ==========================================================
Pre-op Diagnosis:
Cholelithiasis, possible cholecystitis
Post-op Diagnosis:
Cholelithiasis (K80.20) with obstruction (K80.21)
Cholelithiasis with acute cholecystitis (K80.00) and obstruction (K80.01)
Gangrene of gallbladder in cholecystitis (K82.A1)
Cholelithiasis with chronic cholecystitis (K80.10) and obstruction (K80.11)
Cholelithiasis with acute and chronic cholecystitis (K80.12) with obstruction (K80.13)
Cholelithiasis with other cholecystitis (K80.18) with obstruction (K80.19)
Cholelithiasis, choledocholithiasis with acute cholangitis (K80.32) and obstruction (K80.33)
Cholelithiasis, choledocholithiasis with chronic cholangitis (K80.34) and obstruction (K80.35)
Cholelithiasis, choledocholithiasis with acute and chronic cholangitis (K80.36) and obstruction (K80.37)
Cholelithiasis, choledocholithiasis, with acute cholecystitis (K80.42) with obstruction (K80.43)
Cholelithiasis, choledocholithiasis, with chronic cholecystitis (K80.44) with obstruction (K80.45)
Cholelithiasis, choledocholithiasis, with acute and chronic cholecystitis (K80.46) with obstruction (K80.47)
Acute acalculous cholecystitis (K81.0)
Chronic acalculous cholecystitis (K81.1)
Acute and chronic acalculous cholecystitis (K81.2)
Hydrops of gallbladder (K82.1)
Perforation of gallbladder (K82.2)
Fistula of gallbladder (K82.3)
Cholesterolosis of gallbladder (K82.4)
Biliary dyskinesia (non-functioning gallbladder) (K82.8)
Other diseases of gallbladder (K82.8)
Disease of gallbladder, unspecified (K82.9)
Biliary acute pancreatitis without necrosis or infection (K85.10)
Biliary acute pancreatitis with necrosis, without infection (K85.11)
Biliary acute pancreatitis with necrosis and infection (K85.12)
Umbilical hernia (K42.9)
Procedure Performed:
Robotic assisted, laparoscopic cholecystectomy (47562)
with cholangiogram (47563)
Umbilical hernia repair (49585)
Surgeons: Jon D Nguyen
First Assist: ***
First Assist: Stefania Mercy Epperson, AHP
First Assist: Juanetta Wallace, AHP
Anesthesia: General
Estimated Blood Loss: None
Drains: None
Urine Output: None
Indication:
The patient presented with recurrent abdominal pain, associated with nausea and vomiting.
***
Laboratory studies were notable for leukocytosis and elevated liver enzymes.
Abdominal ultrasound demonstrated cholelithiasis.
A HIDA scan revealed non-visualization of the gallbladder, consistent with cystic duct obstruction.
These findings, along with the diagnosis, were thoroughly discussed with the patient. Management options were reviewed, including (1) conservative observation with dietary modification, (2) further diagnostic evaluation, such as additional imaging or gastroenterology consultation with possible endoscopy, and (3) definitive surgical intervention with cholecystectomy.
The risks of surgery were explained in detail, including but not limited to bleeding, infection, postoperative pain, bile leak, injury to the common bile duct, injury to adjacent structures (such as the intestine or duodenum), conversion to open procedure, anesthesia-related complications, and the possibility of retained stones or need for further intervention. The anticipated benefits of surgery were also discussed, including relief of current symptoms and prevention of future complications such as acute cholecystitis, choledocholithiasis, or gallstone-related pancreatitis. The patient demonstrated clear understanding of the indications, alternatives, benefits, and risks of the procedure. After thoughtful consideration and opportunity to ask questions, the patient provided informed consent to proceed with cholecystectomy.
Operative Findings:
***
The gallbladder appeared normal.
The gallbladder appeared chronically inflamed characterized by pericholecystic fibrotic scarring.
The gallbladder was distended and inflamed, with wall thickening, pericholecystic edema, and fibrotic adhesions consistent with acute-on-chronic cholecystitis.
Procedure Description:
Indocyanine green, 5 mg, was administered preoperatively before the patient was taken to the operating room. After induction of general endotracheal anesthesia, the abdomen was prepared and draped in the standard sterile fashion. A universal protocol time-out was performed, verifying patient identity, planned procedure (laparoscopic cholecystectomy), surgical site, and confirmation of preoperative antibiotic administration.
Initial abdominal access was obtained using an 8-mm optical trocar inserted at Palmer's point in the left upper quadrant via the Optiview technique. Pneumoperitoneum was established with CO? insufflation to 15 mmHg. The viscera at the entry site were inspected laparoscopically, revealing no injury from trocar placement. Under direct visualization, three additional 8-mm robotic trocars were placed: one at the umbilicus, one in the right flank, and one midway between these two ports.
The operating table was placed in 15-degree reverse Trendelenburg position with a slight leftward tilt. The da Vinci robotic system was then brought into the field, targeted, and docked. Instruments were introduced with bipolar forceps in arm 1, a 30-degree camera in arm 2, monopolar curved scissors in arm 3, and ProGrasp forceps in arm 4.
***[Intraoperative findings:]***
The gallbladder was noted to be inflamed and markedly distended. Omental and filmy adhesions were carefully lysed using a combination of blunt dissection with an atraumatic grasper and sharp dissection with electrocautery as required.
***[Optional decompression section:]***
Due to severe tense distension that impaired safe grasping and manipulation, the gallbladder was decompressed. A long aspiration needle was introduced through the midclavicular trocar, and bile was aspirated from the fundus under direct vision.
The gallbladder fundus was grasped via the most lateral trocar and retracted superolaterally. The infundibulum was grasped through the midclavicular trocar and retracted anteroinferiorly, establishing a clear critical view of safety within Calot's triangle.
Dissection commenced laterally with incision of the overlying peritoneum. The infundibulum was mobilized, and dissection advanced proximally to definitively identify the cystic duct–gallbladder junction. The cystic duct was circumferentially dissected free. Medial dissection then isolated the cystic artery, which was carefully mobilized while remaining in close proximity to the gallbladder to minimize risk to adjacent structures.
The cystic duct was secured with two Hem-o-lok clips proximally and one distally prior to division. The cystic artery was doubly clipped proximally and divided distally with electrocautery. The gallbladder was separated from the liver bed using hook electrocautery, with meticulous attention to hemostasis. The specimen was placed into an endoscopic retrieval bag and extracted through the umbilical port site.
All trocars were removed. The umbilical fascial defect was closed with interrupted figure-of-eight 0-Vicryl sutures. Skin incisions were approximated with running subcutaneous 4-0 Monocryl sutures, and Dermabond tissue adhesive was applied. The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.
***[Optional surgical assistance:]***
A qualified surgical assistant was present for the duration of the case and provided critical retraction, exposure, and tissue manipulation to ensure safe and effective completion of the operation.
Case Status: Elective: able to defer w/o increased risk
Wound class: Clean
Infection Present at the time of surgery? No
Specimens: Gallbladder
Procedure for cancer: Procedure for Cancer? No
Complications: No
Disposition: PACU
Condition: stable
Attending Attestation: I performed the procedure.
*** ==========================================================
Pre-op Diagnosis:
Post-op Diagnosis: Initial LEFT *** RIGHT inguinal hernia, without obstruction or gangrene (ICD10: K40.90)
Initial LEFT *** RIGHT inguinal hernia, without obstruction or gangrene, recurrent (ICD10: K40.91)
Initial LEFT *** RIGHT inguinal hernia, with obstruction, without gangrene (ICD10: K40.30)
Initial LEFT *** RIGHT inguinal hernia, with obstruction, without gangrene, recurrent (ICD10: K40.31)
Initial LEFT *** RIGHT inguinal hernia, with gangrene (ICD10: K40.41)
Initial bilateral inguinal hernia, without obstruction or gangrene (ICD10: K40.20)
Initial bilateral inguinal hernia, without obstruction or gangrene, recurrent (ICD10: K40.21)
Initial bilateral inguinal hernia, with obstruction, without gangrene (ICD10: K40.00)
Initial bilateral inguinal hernia, with obstruction, without gangrene, recurrent (ICD10: K40.01)
Initial bilateral inguinal hernia, with gangrene (ICD10: K40.11)
Procedure performed:
Robotic assisted, laparoscopic repair of LEFT *** RIGHT initial inguinal hernia (CPT: 49650)
Robotic assisted, laparoscopic repair of LEFT *** RIGHT recurrent inguinal hernia (CPT: 49651)
Surgeons: Jon D Nguyen
First Assistant: None
First Assist: First Assist: Stefania Mercy Epperson, AHP
First Assist: Juanetta Wallace, AHP
***
Anesthesia: General
Indication:
The patient presented with a symptomatic LEFT *** RIGHT inguinal hernia, characterized by groin discomfort and a reducible bulge that interfered with daily activities.
Nonoperative management (watchful waiting) versus definitive surgical repair was discussed in detail, including the risks and benefits of each approach. The risks of watchful waiting include potential progression to incarceration or strangulation, which may necessitate emergency surgery with increased morbidity.
The risks of robotic-assisted laparoscopic inguinal hernia repair were reviewed, including but not limited to: bleeding, infection, seroma or hematoma formation, injury to adjacent structures (such as the vas deferens, testicular vessels, bladder, bowel, or major vascular structures), mesh-related complications (infection, migration, or erosion), chronic groin pain, numbness or neuralgia, testicular ischemia or atrophy, recurrence of the hernia, risks associated with general anesthesia and pneumoperitoneum (including cardiovascular or respiratory complications), and the potential need for conversion to open surgery or additional procedures.
The benefits of surgical repair, including relief of symptoms and prevention of complications such as incarceration or strangulation, were also outlined. Alternative approaches, including open repair, were mentioned.
The patient verbalized understanding of the discussed risks, benefits, and alternatives and provided informed consent to proceed with robotic-assisted laparoscopic inguinal hernia repair.
Procedure Description:
The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced without complication. The abdomen and bilateral groin regions were prepped and draped in the standard sterile fashion. A surgical time-out was performed, confirming correct patient identity, procedure, site, and laterality (robotic-assisted LEFT *** RIGHT laparoscopic inguinal hernia repair). Prophylactic intravenous antibiotics were administered prior to incision.
An 8 mm robotic trocar was inserted in the left upper quadrant using the Optiview technique with a 0-degree 5 mm camera through an adapter. Pneumoperitoneum was established with CO2 insufflation to a pressure of 15 mmHg. Under direct visualization, two additional 8 mm robotic trocars were placed in the right upper quadrant and epigastrium. All trocars were inserted through the musculature to minimize the risk of trocar-site hernia.
Diagnostic laparoscopy confirmed an inguinal hernia on the LEFT *** RIGHT side. The peritoneum was incised in the midline, inferior to the umbilicus and superior to the hernia defect. Peritoneal dissection was carried out medially in the plane deep to the rectus abdominis muscle to the pubic symphysis and laterally in the plane deep to the transversalis fascia to the anterior superior iliac spine. Dissection was then performed along the inferior epigastric vessels with careful preservation of these vessels and underlying structures.
The hernia sac and preperitoneal lipoma were identified, meticulously dissected from surrounding tissues, and reduced into the preperitoneal space. The vas deferens and testicular vessels were identified and preserved throughout the dissection. The dissection was extended to fully expose the myopectineal orifice, ensuring adequate clearance for mesh placement to cover all potential hernia defects (direct, indirect, and femoral).
A prosthetic mesh was introduced into the abdominal cavity, positioned to overlap the myopectineal orifice with sufficient margin, and secured with interrupted 2-0 Vicryl sutures: one to Cooper's ligament medially and one to the transversalis fascia laterally. The peritoneum was reapproximated over the mesh using a running 3-0 V-Loc barbed absorbable suture, completely covering the mesh to prevent intra-abdominal adhesion formation.
Meticulous hemostasis was confirmed throughout the operative field. The robot was undocked, and all robotic instruments were removed. Pneumoperitoneum was evacuated. Fascial defects at the 8 mm trocar sites were not closed, as they were placed through muscle with low hernia risk. Skin incisions were closed with interrupted 4-0 monocryl subcuticular sutures and reinforced with dermabond. Sterile dressings were applied.
The patient tolerated the procedure well, was extubated in the operating room, and was transferred to the postanesthesia care unit in stable condition.
*** Surgical assistance
A qualified surgical assistant was present throughout the procedure and provided essential retraction, exposure, and tissue manipulation to facilitate safe and efficient completion of the operation.
Estimated Blood Loss: 5 mL
Drains: None
Urine Output: None
Case Status: Elective: able to defer w/o increased risk
Wound class: Clean
Infection Present at the time of surgery? No
Specimens: None
Procedure for cancer: Procedure for Cancer? No
Complications: No
Disposition: PACU
Condition: Stable
Attending Attestation: I performed the procedure.
Date of Service: ***
Chief Complaint/Reason for Consultation: Abdominal pain *** Gallstones
History of Present Illness:
The patient presented with recurrent epigastric abdominal pain radiating to the right upper quadrant. The pain was moderate to severe, postprandial in timing, lasting 1-2 hours per episode, and relieved by antacids or over-the-counter analgesics. It was associated with nausea and occasional vomiting but not exacerbated by specific foods beyond fatty meals. Symptoms began [insert duration, e.g., 3 months ago] and had increased in frequency to 2-3 times weekly. The patient denied fever, chills, jaundice, dark urine, clay-colored stools, diarrhea, constipation, dysuria, hematuria, cough, shortness of breath, chest pain, or lower extremity edema.
Past Medical History:
*** [Insert relevant history, e.g., Hypertension, Diabetes mellitus, Hyperlipidemia, or None]
Past Surgical History:
***[Insert relevant history, e.g., Appendectomy in 2010, or None]
Allergies: No known drug allergies. ***
Medications:
***[Insert current medications, dosages, and frequencies, e.g., Lisinopril 10 mg daily, or None]
Social History:
The patient denied tobacco use, alcohol consumption, or illicit drug use. [Insert additional details, e.g.,
Occupation: Office worker;
Lives with family; No recent travel.]
Family History: [Insert relevant history, e.g., Mother with gallstones; Father with coronary artery disease, or Noncontributory]
Review of Systems:
Positive findings were as noted in the History of Present Illness. All other systems were negative unless otherwise specified.
Constitutional: Denied fever, chills, fatigue, weight loss, or night sweats.
Head: Denied headache, facial pain, or masses.
Eyes: Denied pain, bleeding, discharge, diplopia, or vision changes.
Ears: Denied pain, bleeding, discharge, tinnitus, or hearing changes.
Nose: Denied pain, bleeding, discharge, epistaxis, or smell changes.
Mouth: Denied pain, bleeding, masses, dental issues, or gum problems.
Throat: Denied sore throat, hoarseness, dysphagia, or voice changes.
Neck: Denied pain, stiffness, masses, or lymphadenopathy.
Cardiovascular: Denied chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, or edema.
Respiratory: Denied cough, wheezing, hemoptysis, pleuritic pain, or dyspnea.
Gastrointestinal: Denied nausea, vomiting, diarrhea, constipation, melena, hematochezia, or groin pain (beyond HPI).
Genitourinary: Denied dysuria, frequency, urgency, incontinence, hematuria, or flank pain.
Musculoskeletal: Denied bone pain, joint pain, muscle weakness, or arthritis.
Integumentary (skin and breast): Denied pain, rash, abscesses, masses, pruritus, or changes in moles.
Neurological: Denied numbness, paresthesias, weakness, falls, syncope, seizures, or dizziness.
Psychiatric: Denied depression, anxiety, hallucinations, or suicidal ideation.
Endocrine: Denied heat/cold intolerance, polydipsia, polyuria, or thyroid issues.
Hematologic/Lymphatic: Denied easy bruising, bleeding, clotting disorders, or lymphadenopathy.
Physical Exam:
Vital Signs: Blood pressure [insert value, e.g., 120/80 mmHg]; Pulse [insert value, e.g., 80 bpm]; Respiratory rate [insert value, e.g., 16/min]; Temperature [insert value, e.g., 98.6°F]; Weight [insert value, e.g., 70 kg]; Height [insert value, e.g., 170 cm]; BMI [insert value, e.g., 24.2].
General: The patient appeared well-nourished, comfortable, and in no acute distress.
Eyes: Conjunctivae clear without discharge or scleral icterus. Pupils equal, round, and reactive to light. Extraocular movements intact.
Ears, Nose, Mouth, and Throat: Normal appearance without discharge, lesions, or hoarseness.
Neck: Supple and symmetric. Trachea midline. No masses, thyromegaly, or lymphadenopathy.
Cardiovascular: No jugular venous distention or edema. Heart sounds regular rate and rhythm without murmurs, rubs, or gallops.
Respiratory: Normal respiratory effort and chest excursion. Lungs clear to auscultation bilaterally without wheezes, rales, or rhonchi.
Gastrointestinal: Abdomen nondistended, soft, and nontender with normal bowel sounds. No guarding, rebound, hepatosplenomegaly, masses, or hernias. Murphy's sign negative.
Genitourinary: Not examined.
Musculoskeletal: All extremities normal in appearance with full range of motion. No deformities or tenderness.
Skin: Normal color, warm, and dry without rashes, abscesses, ulcers, or masses.
Neurological: Alert and oriented to person, place, time, and situation. Cranial nerves II-XII intact. Symmetric facial expression and normal speech. No focal deficits.
Psychiatric: Calm, cooperative, and pleasant with normal mood, affect, and thought process.
Laboratory Tests and Imaging Studies:
CBC and CMP were unremarkable.
Abdominal ultrasound revealed gallstones without evidence of cholecystitis, gallbladder wall thickening, pericholecystic fluid, or common bile duct dilation.
Assessment:
Symptomatic cholelithiasis (biliary colic) (ICD-10: K80.20).
Counseling:
Relevant findings from the history, physical examination, laboratory results, and imaging studies, along with the diagnosis, were discussed with the patient. Management options were reviewed, including conservative observation with dietary modifications, further diagnostic evaluation (e.g., additional imaging or gastroenterology consultation with possible endoscopy), and definitive surgical intervention via cholecystectomy.
Surgical risks were explained, including bleeding, infection, postoperative pain, bile leak, common bile duct injury, injury to adjacent structures (e.g., intestine or duodenum), conversion to open procedure, anesthesia complications, retained stones, and need for further intervention. Benefits were discussed, including symptom relief and prevention of complications such as acute cholecystitis, choledocholithiasis, or gallstone pancreatitis. The patient demonstrated understanding of indications, alternatives, benefits, and risks, and had opportunity to ask questions. The patient elected to proceed with cholecystectomy.
Plan:
Proceed with robotic cholecystectomy.
Obtain preoperative clearance if indicated (e.g., EKG, chest X-ray).
Instruct patient on NPO status, preoperative preparation, and postoperative expectations.
Coordination of Care:
Surgery was scheduled, required documentation faxed, and staff instructed to verify insurance preauthorization. Total time spent on evaluation, counseling, and care coordination: 90 minutes.
### Review of Systems Checklist
Please check **Yes** if you have experienced any of these symptoms in the past few months, or **No** if you have not.
#### General/Whole Body
- [ ] Yes [ ] No Unexplained fever or chills
- [ ] Yes [ ] No Feeling very tired or weak (fatigue)
- [ ] Yes [ ] No Unexplained weight loss or gain
- [ ] Yes [ ] No Night sweats
#### Head and Face
- [ ] Yes [ ] No Headaches
- [ ] Yes [ ] No Pain in your face
- [ ] Yes [ ] No Lumps or bumps on your head or face
#### Eyes
- [ ] Yes [ ] No Eye pain
- [ ] Yes [ ] No Redness, discharge, or bleeding from eyes
- [ ] Yes [ ] No Blurry vision or other changes in eyesight
- [ ] Yes [ ] No Double vision
#### Ears
- [ ] Yes [ ] No Ear pain
- [ ] Yes [ ] No Ringing in the ears (tinnitus)
- [ ] Yes [ ] No Discharge or bleeding from ears
- [ ] Yes [ ] No Hearing loss or changes
#### Nose and Sinuses
- [ ] Yes [ ] No Nose pain or sinus pressure
- [ ] Yes [ ] No Nosebleeds
- [ ] Yes [ ] No Runny nose or discharge
- [ ] Yes [ ] No Loss of smell
#### Mouth and Throat
- [ ] Yes [ ] No Mouth pain, sores, or bleeding
- [ ] Yes [ ] No Problems with teeth or gums
- [ ] Yes [ ] No Sore throat
- [ ] Yes [ ] No Hoarse voice or voice changes
- [ ] Yes [ ] No Difficulty swallowing
#### Neck
- [ ] Yes [ ] No Neck pain or stiffness
- [ ] Yes [ ] No Swollen glands or lumps in neck
#### Heart and Circulation
- [ ] Yes [ ] No Chest pain or discomfort
- [ ] Yes [ ] No Fast or irregular heartbeat (palpitations)
- [ ] Yes [ ] No Shortness of breath when lying down
- [ ] Yes [ ] No Swelling in legs or ankles
#### Lungs and Breathing
- [ ] Yes [ ] No Cough
- [ ] Yes [ ] No Wheezing
- [ ] Yes [ ] No Shortness of breath
- [ ] Yes [ ] No Pain when breathing
- [ ] Yes [ ] No Coughing up blood
#### Stomach and Digestive System
- [ ] Yes [ ] No Nausea or vomiting
- [ ] Yes [ ] No Diarrhea
- [ ] Yes [ ] No Constipation
- [ ] Yes [ ] No Blood in stool (black or red)
- [ ] Yes [ ] No Pain in groin or possible hernia
#### Urinary System
- [ ] Yes [ ] No Pain or burning when urinating
- [ ] Yes [ ] No Urinating more often than usual
- [ ] Yes [ ] No Sudden strong urge to urinate
- [ ] Yes [ ] No Blood in urine
- [ ] Yes [ ] No Pain in your side or back (flank pain)
#### Muscles, Bones, and Joints
- [ ] Yes [ ] No Muscle, joint, or bone pain
- [ ] Yes [ ] No Muscle weakness
- [ ] Yes [ ] No Swelling or stiffness in joints
#### Skin and Breast
- [ ] Yes [ ] No Rash, redness, or itching
- [ ] Yes [ ] No Lumps, sores, or abscesses on skin
- [ ] Yes [ ] No New or changing moles
- [ ] Yes [ ] No Lumps or pain in breasts
#### Nervous System
- [ ] Yes [ ] No Numbness or tingling
- [ ] Yes [ ] No Weakness in arms or legs
- [ ] Yes [ ] No Dizziness or fainting
- [ ] Yes [ ] No Frequent falls
- [ ] Yes [ ] No Seizures
#### Mood and Mental Health
- [ ] Yes [ ] No Feeling depressed or sad most days
- [ ] Yes [ ] No Feeling anxious or nervous
- [ ] Yes [ ] No Thoughts of harming yourself
#### Hormones (Endocrine)
- [ ] Yes [ ] No Feeling too hot or too cold often
- [ ] Yes [ ] No Urinating a lot more than usual
- [ ] Yes [ ] No Feeling very thirsty all the time
#### Bleeding and Clotting
- [ ] Yes [ ] No Easy bruising
- [ ] Yes [ ] No Bleeding that is hard to stop
- [ ] Yes [ ] No Swollen lymph nodes anywhere
If you checked “Yes” to any symptom, please describe it briefly:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Patient Signature: _______________________________ Date: __________________