What should be included in a comprehensive laparoscopic cholecystectomy operative note for a typical patient (e.g., 45‑year‑old female, ASA II)?

Comprehensive Laparoscopic Cholecystectomy Operative Note

A complete laparoscopic cholecystectomy operative note must document the Critical View of Safety achievement, all anatomical structures identified, any complications or difficulties encountered, and specific technical details to ensure medico-legal protection and guide postoperative management. 1

Essential Patient and Procedure Identification

• Patient demographics: Full name, medical record number, date of birth, age (e.g., 45 years), and sex 2, 3
• Date and time: Exact date of surgery, start time, and end time of procedure 2, 4
• Preoperative diagnosis: Specify indication (e.g., symptomatic cholelithiasis, acute calculous cholecystitis) 1
• Postoperative diagnosis: Confirm or modify based on intraoperative findings 2, 4
• ASA physical status: Document classification (e.g., ASA II) as this impacts risk stratification 1
• Surgeon and assistant names: Include attending surgeon and all assistants present 2, 4
• Anesthesia type: General anesthesia with endotracheal intubation 3

Critical Preoperative and Intraoperative Details

Patient Positioning and Access

• Patient position: Supine with reverse Trendelenburg positioning 5
• Trocar placement: Document number, size, and exact location of each trocar (umbilical, epigastric, right subcostal positions) 6
• Pneumoperitoneum pressure: Typically 12-15 mmHg 5

Critical View of Safety Documentation

This is the most medico-legally important section and must be explicitly documented. 1, 5

• Hepatocystic triangle clearance: State whether all fat and fibrous tissue were cleared from the hepatocystic triangle with no exposure of the common bile duct 1, 5
• Gallbladder bed separation: Document that the lower third of the gallbladder was separated from the liver bed 1, 5
• Two-structure rule: Explicitly state that only two structures (cystic duct and cystic artery) were visualized entering the gallbladder 1, 5
• If CVS not achieved: Document why CVS could not be achieved and what alternative approach was used (subtotal cholecystectomy, conversion to open) 1, 5

Anatomical Findings and Variations

• Gallbladder appearance: Size, wall thickness, presence of inflammation, adhesions, or gangrenous changes 1
• Anatomical variations: Any aberrant anatomy including short cystic duct, accessory ducts, vascular anomalies, or second cystic artery 1
• Calot's triangle assessment: Degree of inflammation, fibrosis, or difficulty in dissection 1
• Liver bed condition: Presence of adhesions, inflammation, or bleeding 1

Procedural Steps and Technical Details

Dissection Technique

• Dissection method: Specify use of electrocautery, blunt dissection, or sharp dissection 5
• Cystic artery identification: Document identification, number of clips applied (typically 2 proximally, 1 distally), and division 5, 6
• Cystic duct identification: Document identification, number of clips applied (typically 2 proximally, 1 distally), and division 5, 6
• Timeout performed: State whether a timeout was performed before transecting any ductal structures 1
• Second opinion: Document if another surgeon was consulted during difficult dissection 1

Adjunctive Procedures

• Intraoperative cholangiography: If performed, document findings (normal anatomy, filling defects, contrast flow to duodenum) 1, 5
• Laparoscopic ultrasound: If used, document findings 1
• ICG fluorescence: If utilized for biliary visualization, document findings 1

Gallbladder Removal

• Dissection from liver bed: Technique used (electrocautery, harmonic scalpel) 6
• Specimen extraction site: Document location (umbilical port, epigastric port) 6
• Specimen retrieval: Use of retrieval bag to prevent spillage 5
• Bile spillage: If occurred, document extent and irrigation performed 6
• Stone spillage: If occurred, document retrieval attempts 6

Complications and Difficulties

Any deviation from routine must be explicitly documented. 1

Intraoperative Complications

• Bile duct injury: If suspected or confirmed, document exact nature, location, and management 1
• Vascular injury: Document any injury to hepatic arteries, portal vein, or other vessels 1
• Bleeding: Source, estimated blood loss, and hemostasis method 1
• Gallbladder perforation: Document location and bile/stone spillage 7, 6
• Bowel or other organ injury: Any inadvertent injury and repair 1

Unusual Findings Requiring Documentation

• Bile drainage from unexpected location (not from gallbladder) 1
• Bile draining from tubular structure suggesting duct injury 1
• Large artery posterior to cystic duct 1
• Bile duct traceable to duodenum suggesting common bile duct misidentification 1
• Severe hemorrhage or inflammation 1

Conversion and Alternative Procedures

• Conversion to open: If performed, document specific indication (severe inflammation, adhesions, bleeding, suspected bile duct injury) and timing 1, 8
• Subtotal cholecystectomy: If performed instead of complete cholecystectomy, document reason (inability to achieve CVS, severe inflammation, gangrenous gallbladder) 1, 5

Closure and Postoperative Details

• Irrigation: Document irrigation of surgical field and fluid used 3
• Hemostasis: Confirm adequate hemostasis achieved 3, 4
• Drain placement: If drain placed, document type, size, and location 1
• Fascial closure: Document closure of trocar sites ≥10mm 3, 4
• Skin closure: Method used (subcuticular suture, staples, glue) 3, 4
• Specimen sent: Confirm gallbladder sent to pathology 2, 4
• Estimated blood loss: Quantify in milliliters 1, 2
• Operative time: Total duration in minutes 1, 2

Postoperative Instructions

• Antibiotic administration: Document antibiotics given at induction and whether postoperative antibiotics are needed (typically not needed if source control complete in uncomplicated cases) 7, 3
• Diet advancement: Specify when patient may resume oral intake 3, 4
• Activity restrictions: Document any limitations 3
• Pain management plan: Specify analgesic regimen 3
• Follow-up arrangements: When and where patient should be seen 4
• Pathology follow-up: Plan for reviewing pathology results 4

Special Considerations for High-Risk Patients

Elderly Patients (>65 years)

• Document that laparoscopic approach was attempted first unless absolute contraindications existed 1, 7
• Frailty assessment: If applicable, note any frailty considerations 1
• Conversion risk factors: Document presence of fever, leukocytosis, elevated bilirubin, or previous upper abdominal surgery 1, 8

Acute Cholecystitis

• Timing: Document days from symptom onset and hospital admission 7
• Severity grading: Note presence of gangrenous changes, perforation, or abscess 7
• Tokyo Guidelines grade: If applicable 7

Cirrhotic Patients

• Child-Pugh score: Document classification (A, B, or C) 1
• Portal hypertension signs: Note varices, portal cavernoma, or neovascularization 1

Documentation Quality Standards

Use structured electronic proforma when available, as this improves completeness from 8.3% to 79.2% and ensures 100% legibility. 2, 3, 4

• Legibility: If handwritten, ensure complete legibility (only 66% of handwritten notes are fully legible) 3, 9
• Avoid abbreviations: Minimize use of non-standard abbreviations 4
• Completeness: Include all 18 RCS guideline parameters 4
• Timeliness: Complete note immediately after surgery while details are fresh 2
• Signature and credentials: Include full signature, printed name, and credentials 2, 4