What should be included in the operation report for a laparoscopic (lap) cholecystectomy (chole)?

Operative Report for Laparoscopic Cholecystectomy

The operative report for laparoscopic cholecystectomy must document the Critical View of Safety, any anatomical variations, gallbladder perforation with stone spillage, and detailed intraoperative findings to ensure medicolegal protection and guide future management of potential complications. 1, 2

Essential Components of the Operative Report

Clinical Context and Indication

• Document the primary indication for surgery (symptomatic cholelithiasis, acute cholecystitis, chronic cholecystitis, biliary dyskinesia) 1
• Note whether the procedure was elective or emergent, as emergency cholecystectomy carries higher risk of bile duct injury 1
• Include relevant history such as prior episodes of acute cholecystitis, which increases bile duct injury risk (OR 1.34) 1

Intraoperative Findings

• Critical View of Safety (CVS) documentation is mandatory: Explicitly state whether CVS was achieved, documenting visualization of only 2 structures entering the gallbladder (cystic duct and cystic artery) with clear exposure of the hepatocystic triangle 2
• The hepatocystic triangle must be cleared of all tissue with no exposure of the common bile duct 2
• Document the degree of inflammation (acute vs chronic cholecystitis, adhesions, fibrosis) 1
• Note gallbladder wall thickness and any evidence of perforation 1

Anatomical Variations

• Document any biliary anatomical variations identified, including aberrant ducts, accessory ducts, or ducts of Luschka 1, 3
• Note any vascular variations, particularly of the cystic artery and right hepatic artery 1

Cholangiography Findings (If Performed)

• Include cholangiogram images and interpretation if intraoperative cholangiography was performed 1
• Document biliary anatomy, presence of filling defects, and free flow of contrast into the duodenum 1

Gallbladder Perforation and Stone Spillage

• Mandatory documentation of gallbladder perforation and stone spillage is critical, as complications can present months to years later (median 36 months, range 1-180 months) 1
• Specify the location of spilled stones (most common sites: right subhepatic, perihepatic, retroperitoneal, right flank, pelvis) 1
• Document the estimated number and size of spilled stones 1
• Note attempts at stone retrieval and success rate 1
• This documentation is essential because 56.5% of patients with retained stones develop abscesses requiring intervention, and 87% require surgical procedures for complications 1

Operative Data

• Operative time from initial incision to closure 1
• Estimated blood loss 1
• Energy device used for dissection (monopolar, bipolar, ultrasonic, etc.) 1
• Need for conversion to open procedure and reason for conversion 1

Bile Duct Injury Documentation (If Applicable)

• If bile duct injury occurs, create a detailed drawing of the injury with anatomical landmarks 1
• Classify the injury using Strasberg's classification (most commonly used) or ATOM classification (most comprehensive) 1, 4
• Document biliary drain placement with type, size, and location 1
• Note any associated vascular injuries, particularly to the right hepatic artery 1, 2

Video Documentation

• Preserve videotape of the procedure whenever available, particularly for medicolegal purposes and quality review 1

Critical Safety Pitfalls

Never clip or transect any structure before achieving the Critical View of Safety - clipping the common bile duct represents a catastrophic Type E bile duct injury requiring complex hepaticojejunostomy reconstruction 2, 4

Inform patients and general practitioners about stone spillage when it occurs, as this enables earlier diagnosis of delayed complications (abscesses, fistulas, chronic pain) that may present years later 1

Document any deviation from standard technique, including difficult dissection requiring alternative approaches, as this information is crucial for managing potential complications 1