Elizabeth Blair Archibald

Clinical 01/30/2018
Pre-op, OR, PACU

Laparoscopic Cholecystectomy

48-year-old male patient present in ED 01/06/2018 for RUQ abdominal pain radiating to
right scapula. Physical exam, clinical presentation, laboratory results, and imaging are
consistent with cholecystitis.

Gall bladder was laparoscopically removed today. This surgery is preferred over the
traditional, open surgery, because the surgical sites will heal faster and there is less
pain associated with surgery.

Preoperatively, a 20 G IVC was instilled to the right hand. NS was infused TKO, and
patient was administered 2 GM Cefazolin IV before surgery.

The patient was sedated under general anesthesia by CRNA, and an endotracheal tube
was placed. The CRNA infused the surgical areas with lidocaine and epinephrine, to
reduce bleeding operatively, and reduce pain post operatively.

A total of 4 small incisions were made. One incision was about a half of an inch just
superior to the umbilicus for the scope to enter the abdomen. The three other incisions
were a quarter to half an inch in length and were used for the surgical instruments. The
three surgical instrument incisions were held open with a trochanter. A trochanter acts
as a tunnel for the instruments, and hold the incisions open so that the surgeon does
not need to keep re-opening/puncturing the patient to insert or trade out tools.

Surgery proved that the patient has been suffering from chronic cholecystitis, because
of the small size of gall bladder (the gall bladder will most often be large and inflamed,
but with a chronic condition the gall bladder can shrink), and excess adipose tissue
build up around organ.

After removal of the gall bladder, a stone was palpated. The surgeon allowed the
student to open the gall bladder, and the stone was approximately half an inch in
diameter and yellow in color.

The gall bladder, and the stone will be sent to histopathology for evaluation.

Patient recovered well. He was treated for nausea with 4 MG of Ondansetron IVP, and
a total of 0.6 MG Hydromorphone IVP, but was cleared for discharge within an hour post
op.

Lesion Removal to Right Lower Extremity

94-year-old female patient has a history of squamous cell carcinoma, and has had
multiple lesion removals. Today, a lesion (almost large enough to be a mass) was being
removed from the right lower leg just medial to midline on the anterior shin area.

Preoperatively, a 22 G IVC was instilled to the left hand. NS was infused TKO, and
patient was administered 1 GM Cefazolin IV before surgery.

Patient was minimally sedated with Midazolam 0.5 MG IV & Propofol 25 ML IV, and was
on 2 L oxygen via nasal cannula. Patient was not intubated.

32 ML Lidocaine with Epinephrine was instilled into lower right leg around excisional
area.

Wide margins were made using a 10 blade. Margins were approximately 3 inches wide
x 4 inches long x 2 inches deep. Lesion was tacked on the outside. The surgeon then
used electric cautery to remove the rest of the lesion with wide margins. Lesion was
then tacked with various sutures on the inferior aspect. Superior and inferior tacks were
made to maintain shape/integrity of mass for histopathology.

Skin graft not needed. Closed excision with minimal tension. Prolene and Vicryl of
various sizes utilized.

2 ML Lidocaine with Epinephrine instilled into left nose area for punch biopsy. Closed
using 4/0 Prolene.

Lesion removal and punch biopsy sent to histopathology for analysis.