Laparoscopic Cholecystectomy Operative Note

Date of Procedure: [Date of procedure]

Patient: [Full name and identifier (MRN or DOB)]

Facility: [Facility name]

Start/End Time: [Start time – End time]

Case Priority: [elective / urgent / emergent]

Primary Surgeon: [Name, credentials]

Assistant(s): [Name(s), role(s)] (If non-primary operator performed key portions, specify tasks performed)

Anesthesia: [Anesthesia provider and type]

Diagnoses and Procedure

Preoperative Diagnosis: [Working diagnosis prompting surgery, including acuity when relevant]

Postoperative Diagnosis: [Final diagnosis based on intraoperative findings]

Procedure(s) Performed: Laparoscopic cholecystectomy [additional procedures if performed: intraoperative cholangiography, lysis of adhesions, subtotal cholecystectomy (fenestrating / reconstituting), drain placement, conversion to open]

Indication: [Brief rationale for surgery timing; include relevant symptom history and key supporting studies (ultrasound, HIDA, MRCP, pancreatitis history as applicable)]

Operative Findings

• [Gallbladder condition: distended / contracted / inflamed / gangrenous / perforated / empyema]
• [Stone burden and location if clinically meaningful]
• [Adhesions: location and extent; impact on exposure or dissection]
• [Bile spillage and management if occurred]
• [Liver bed appearance]
• [Anatomic variants or distortion if present]

Operative Narrative

Entry and Port Placement: [Entry technique (Veress / optical trocar / Hasson), entry site, pneumoperitoneum details, trocar sites and sizes] (Note deviations from standard placement with rationale)

Exposure: [Retraction strategy; adhesiolysis if it meaningfully increased complexity]

Biliary Anatomy Identification:

• If Critical View of Safety (CVS) achieved:
  • Hepatocystic triangle cleared of fat and fibrous tissue: [yes / no]
  • Lower third of gallbladder separated from liver bed exposing cystic plate: [yes / no]
  • Two and only two structures seen entering the gallbladder: [yes / no]
  • Pause performed before clipping: [yes / no]
  • Photo/video documentation: [obtained and stored in (location) / not obtained]
• If CVS not achievable:
  • Reason: [severe inflammation / bleeding / fibrosis / Mirizzi physiology / other]
  • Alternative strategy: [intraoperative cholangiography / fundus-first approach / subtotal cholecystectomy (fenestrating / reconstituting) / conversion to open]
  • [Description of how anatomy and safety were addressed]

(If CVS status or alternative strategy is not specified in dictation, do not infer—leave placeholder indicating this must be documented)

Cystic Duct and Artery Control: [Structures identified and controlled; method(s) used: clips / ligature / stapler / energy device] (Note cystic duct abnormalities and management if present: dilated, short, fragile, impacted stone)

Intraoperative Cholangiography: [Not performed / Performed / Attempted]

• If performed or attempted: [Indication; technique; results including intrahepatic filling, CBD visualization, duodenal filling, filling defects or extravasation; actions taken for abnormal findings]
• If not performed: [Brief rationale if relevant] (If not mentioned in dictation, state "Not performed")

Gallbladder Dissection and Removal: [Plane of dissection; instruments used; liver bed hemostasis approach; management of perforation or spillage if occurred; specimen retrieval method and extraction site]

Final Inspection: [Cystic duct stump (bile leak check), cystic artery stump (bleeding check), liver bed (hemostasis); irrigation performed: yes / no]

Drain Placement: [Drain type, location, exit site, and rationale] (Include only if drain placed or if there was specific concern prompting decision not to place)

Closure: [Fascial closure for ports ≥10 mm with suture type; skin closure method; dressings applied]

Conversion or Bailout: [Point in case when decision made, reason, technique used, and how anatomy/safety was addressed] (Include only if conversion to open or subtotal cholecystectomy occurred)

Case Summary

Estimated Blood Loss: [EBL in mL] (Use placeholder if not specified; do not omit)

Specimens: [Gallbladder to pathology; additional specimens if any]

Drains: [Type and location / None]

Complications: [Intraoperative complication(s) with timing and management / No intraoperative complications] (Do not infer absence of complications unless explicitly stated)

Postoperative Plan

Disposition: [PACU then home / observation / admission]

Diet: [Diet advancement plan]

Activity: [Restrictions and lifting guidance]

Pain Management: [Analgesia strategy]

Antibiotics: [None / continue with rationale (acute cholecystitis, perforation, contamination)]

Drain Care: [Suction vs gravity, output monitoring, removal criteria] (Include only if drain placed)

Follow-up: [Clinic visit timeframe; pathology follow-up; escalation triggers (fever, jaundice, persistent pain, bilious drain output)]