Operative notes for open cholecystectomy

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I now have comprehensive information from multiple authoritative surgical textbooks. Here are complete operative notes for open cholecystectomy.

Operative Notes: Open Cholecystectomy

Preoperative Details

Procedure: Open Cholecystectomy Surgeon: [Attending Surgeon Name] Anaesthesia: General anaesthesia Position: Supine

Indications

Symptomatic cholelithiasis / biliary colic
Acute cholecystitis (with factors precluding laparoscopic approach)
Conversion from laparoscopic cholecystectomy (failure to progress, unclear anatomy, uncontrolled bleeding, bile duct injury)
Empyema or gangrenous gallbladder
Inability to tolerate pneumoperitoneum (severe COPD, ejection fraction <20%, hemodynamic instability)
Biliary-enteric fistula or Mirizzi's syndrome

Preoperative Workup

Full blood count, renal function, liver function tests, prothrombin time
Abdominal ultrasound (gallbladder wall thickness, CBD diameter, stones)
ECG and chest X-ray if medically indicated
Risk stratification for CBD stones (see CBD assessment table)
MRCP or ERCP if CBD stones suspected (CBD >10 mm, jaundice, cholangitis, pancreatitis)

Preoperative Preparation

Informed consent (procedure, risks, alternatives, conversion possibility)
Prophylactic antibiotics: second-generation cephalosporin at induction
DVT prophylaxis: subcutaneous heparin + anti-embolic stockings
Patient voids bladder preoperatively (urinary catheterisation generally not required)
Orogastric tube if stomach distended; removed at end of procedure

Operative Procedure

1. Positioning and Preparation

The patient was placed supine on the operating table and general anaesthesia was induced. The abdomen was prepared and draped in the standard sterile fashion.

2. Incision

A right subcostal (Kocher) incision was made approximately 2.5-5 cm below and parallel to the right costal margin, extending from the xiphoid laterally to allow adequate right upper quadrant exposure. The incision was carried through the skin, subcutaneous fat, anterior rectus sheath, rectus abdominis, posterior rectus sheath, and peritoneum under electrocautery haemostasis.

Alternative: An upper midline incision (through the linea alba) was used in emergency settings requiring wide abdominal access.

3. Abdominal Exploration and Exposure

On entering the peritoneal cavity, a systematic inspection of the right upper quadrant was performed. The right lobe of the liver was swept with the hand, and the gallbladder was assessed. Moist laparotomy pads were placed posterior and lateral to the right lobe of the liver to deliver the gallbladder into the field. Additional lap pads were used to pack the small bowel and colon caudally out of the operative field. A fixed (Thompson or similar) retractor was placed to retract the costal margin and free the assistant's hands. Retractors were positioned over the superior liver edge and the gastroduodenal area to place Calot's triangle on stretch.

4. Adhesiolysis

Adhesions from the omentum, colon, or duodenum to the gallbladder were divided using sharp dissection and/or electrocautery.

5. Gallbladder Decompression (if required)

If the gallbladder was tense and distended, it was decompressed at the fundus using a large-gauge aspiration needle and syringe. The puncture site was closed with a PDS suture, which was then used as a traction stitch.

6. Exposure of Calot's Triangle

Two approaches were available:

Antegrade (fundus-first / top-down) approach: Curved clamps were placed on the fundus and infundibulum of the gallbladder. The fundus was retracted anteriorly and superiorly; the infundibulum was retracted inferiorly and laterally. Caudal counter-retraction of the hepatoduodenal ligament stretched and exposed the porta hepatis. A clamp on Hartmann's pouch was retracted laterally to further open Calot's triangle. The left index finger was introduced into the foramen of Winslow to palpate for CBD calculi.

Retrograde approach: Dissection was begun at the hepatocystic triangle on the medial side, with peritoneal incision staying close to the gallbladder. This is now the preferred approach for surgeons trained in laparoscopic technique.

7. Dissection of Calot's Triangle

The peritoneum overlying the cystic duct and cystic artery was incised with electrocautery, staying close to the gallbladder wall. Using careful right-angle dissection and electrocautery, the cystic artery was identified (typically running within the triangle; the Lund node sits superficially over the artery and is a reliable landmark). The cystic duct was cleared in the same manner.

The gallbladder was then retracted medially to open the peritoneum on the lateral side. Dissection was continued until the cystic duct and cystic artery could be traced unambiguously onto the gallbladder, confirming only two structures entered the gallbladder - equivalent to the "critical view of safety." The surgeon introduced the left index finger into the foramen of Winslow to palpate the CBD.

8. Ligation of Cystic Artery

The cystic artery was dissected, double-ligated with 2-0 braided (silk) ties, and divided close to the gallbladder wall to minimise bleeding during liver bed dissection. The right hepatic artery was identified and protected, especially when a short cystic artery was present.

9. Intraoperative Cholangiogram (selective)

A metal clip or 2-0 suture was placed proximally on the cystic duct close to the gallbladder. A small incision was made just distal to it on the anterior surface, and a cholangiogram catheter was passed and secured. Half-strength iodinated contrast was injected under fluoroscopy. Complete opacification of the right and left hepatic ducts, common hepatic duct, CBD, cystic duct junction, and duodenum was achieved. No filling defects were identified. The catheter was removed.

(If CBD stones found: proceed to transcystic common bile duct exploration or choledochotomy as appropriate.)

10. Ligation of Cystic Duct

Two 2-0 braided (silk) suture ties (or metallic clips) were passed around the cystic duct. Ligation was performed close to but not flush with the CBD, avoiding injury to the common bile duct or common hepatic duct. The cystic duct was divided between ligatures. Careful attention was paid not to tent or avulse the bile duct.

11. Gallbladder Dissection from Liver Bed

The gallbladder was dissected from the liver bed using electrocautery, maintaining the correct plane between the gallbladder wall and liver parenchyma. Care was taken to prevent entry into the gallbladder and spillage of bile or stones. Haemostasis of the liver bed was achieved with electrocautery.

12. Retrieval and Specimen Handling

The gallbladder was removed from the operative field and placed in a specimen container. It was opened and inspected for stones, polyps, or features of malignancy. The specimen was sent for histopathological examination.

13. Inspection and Washout

The porta hepatis structures were re-examined - attention was paid to the cystic duct stump, right hepatic artery, and CBD. The liver bed was inspected for haemostasis and bile leakage. The subhepatic space was irrigated with warm normal saline and all irrigant was evacuated.

14. Drain Placement (selective)

A closed-suction or tube drain was placed in the subhepatic space only if:

Concern exists about a possible bile leak
Significant haemorrhage from the liver bed
Intraoperative bile spillage Routine drainage is not mandatory.

15. Wound Closure

Lap pads and retractors were removed. Final count of instruments, needles, and swabs was confirmed correct. The peritoneum and posterior rectus sheath were closed with a continuous 0-PDS suture. The anterior rectus sheath was closed with a looped 0-PDS continuous suture (mass closure technique acceptable). Subcutaneous tissue was irrigated. Skin was closed with interrupted or subcuticular sutures (or staples). Wound dressing was applied.

Intraoperative Findings

Finding	Description
Gallbladder	[e.g., Chronically inflamed, thick-walled; multiple calculi; mucocele]
Cystic artery	[Single / double; short / normal length]
Cystic duct	[Wide / narrow; junction with CBD]
CBD	[Normal calibre / dilated; palpable stones: yes/no]
Liver bed	[Haemostasis achieved; no bile leak]
Adjacent structures	[Adhesions from omentum / duodenum: present/absent]

Estimated Blood Loss

[e.g., <100 mL]

Fluids

[IV crystalloid as per anaesthetic record]

Specimens

Gallbladder - sent for histopathology

Postoperative Instructions

Patient to recovery/HDU as appropriate
IV antibiotics continued for [24 hours / per clinical indication]
DVT prophylaxis continued
Early ambulation encouraged
Drain output monitored daily; removed when <30 mL/day (if placed)
Oral fluids when awake and tolerating; diet advanced as tolerated
Wound review at 7-10 days
Liver function tests if jaundice develops postoperatively (urgent investigation for bile duct injury)

Complications to Counsel Preoperatively

Complication	Notes
Bile duct injury	~0.5% (open approach lower than laparoscopic historically)
Bile leak (cystic duct stump)	Strasberg Type A injury
Haemorrhage (cystic artery, liver bed)	Uncommon
Wound infection	Higher rate than laparoscopic approach
Retained CBD stones	Risk mitigated by selective cholangiography
Visceral injury (bowel, duodenum)	Rare
Mortality	<1%; higher with advanced age and comorbidities

Notes on Difficult Cholecystectomy / Bailout Options

When anatomy is unclear or the hepatocystic triangle is obliterated by inflammation, the following bailout strategies are available (per Bailey & Love's):

Achieve critical view of safety before clipping anything
Subtotal cholecystectomy - leave a remnant of the infundibulum, suture-ligate the cystic duct mucosa from inside (safer than blind dissection in severe inflammation)
Tube cholecystostomy (14 Fr Foley) - temporising measure
Fundus-first (top-down) dissection
Intraoperative cholangiography to map biliary anatomy

Sources:

Fischer's Mastery of Surgery (8th ed.), Open Cholecystectomy, p. 4529-4535
Maingot's Abdominal Operations, Open Cholecystectomy, p. 1023
Bailey and Love's Short Practice of Surgery (28th ed.), p. 1270-1273
Schwartz's Principles of Surgery (11th ed.), p. 1438-1440

Left ingunial mesh hernioplasty and orchidectomy

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I now have comprehensive textbook-sourced detail on both the Lichtenstein mesh repair and radical inguinal orchidectomy technique. I have enough to write complete operative notes for this combined procedure.

Operative Notes: Left Inguinal Mesh Hernioplasty (Lichtenstein) + Left Orchidectomy

Procedure Header

Procedure: Left Inguinal Mesh Hernioplasty (Lichtenstein Tension-Free Repair) + Left Orchidectomy Surgeon: [Attending Surgeon Name] Assistant: [First Assistant Name] Anaesthesia: General / Spinal / Local with sedation (as applicable) Position: Supine Date: [Date]

Indications

For Hernia Repair:

Left inguinal hernia (indirect / direct / pantaloon - specify type)
Symptomatic hernia with risk of incarceration/strangulation

For Orchidectomy (specify applicable):

Suspected/confirmed testicular malignancy (radical inguinal orchidectomy)
Non-viable / necrotic testis (post-torsion, strangulated inguino-scrotal hernia)
Atrophic/non-functional testis with concurrent hernia repair
Cryptorchidism with atrophic testis
Benign or infective pathology not amenable to conservation

Note: When orchidectomy is for testicular cancer, the inguinal approach (not scrotal) is mandatory to avoid disruption of lymphatic drainage patterns.

Preoperative Preparation

Full blood count, urea/electrolytes, coagulation screen, group & save
For malignancy: AFP, beta-hCG, LDH (tumour markers); CT chest/abdomen/pelvis for staging
Scrotal ultrasound (if not already done)
Informed consent: hernia repair, orchidectomy, risks (including infertility counselling if bilateral or solitary testis)
Sperm banking offered preoperatively if fertility relevant
DVT prophylaxis: anti-embolic stockings, LMWH
Prophylactic antibiotics: second-generation cephalosporin at induction
Urinary catheter not routinely required

Operative Procedure

1. Positioning and Preparation

The patient was placed supine on the operating table. Anaesthesia was administered. The left groin, lower abdomen, and scrotum were prepared with antiseptic solution and draped in the standard sterile fashion.

2. Skin Incision

A slightly curvilinear skin incision of approximately 6-8 cm was made one to two fingerbreadths (approximately 2 cm) above and parallel to the left inguinal ligament, extending from just lateral to the pubic tubercle toward the anterior superior iliac spine. The incision was deepened through the skin, subcutaneous fat, and Scarpa's fascia using electrocautery, with careful haemostasis.

3. Exposure of External Oblique Aponeurosis

The external oblique aponeurosis was cleared of overlying soft tissue. The superficial (external) inguinal ring was identified inferomedially. The iliohypogastric and ilioinguinal nerves were identified and carefully preserved.

The external oblique aponeurosis was incised sharply along the line of its fibres through the external inguinal ring using fine scissors. Superior and inferior flaps were reflected to expose the inguinal canal and its contents.

4. Identification and Isolation of Cord Structures

Using a combination of blunt and sharp dissection, the cremaster muscle fibres enveloping the cord were separated. A soft rubber sling (Penrose drain) was passed around the left spermatic cord to mobilise it and provide traction. The ilioinguinal nerve and genital branch of the genitofemoral nerve were identified within the canal and protected throughout.

5. Hernia Sac Identification and Management

For Indirect Hernia: The hernia sac was found attached to the cord in an anteromedial position, passing through the internal ring. The cremaster fibres were divided to expose the sac, which was dissected free from the cord structures. The sac was opened, contents (bowel/omentum) were inspected and found viable, then reduced back into the peritoneal cavity. The sac was ligated with a 2-0 absorbable (Vicryl) transfixion suture at the level of the internal ring and the redundant sac was excised.

For Direct Hernia: The direct defect in the floor of the canal (medial to the inferior epigastric vessels/Hesselbach's triangle) was identified as a bulge posterior to the cord. The sac was invaginated (reduced without excision) back into the preperitoneal space using a purse-string 2-0 absorbable suture.

For Pantaloon Hernia: Both an indirect and direct component were identified and managed as above.

Intraoperative finding: [Specify type - indirect / direct / pantaloon / sliding hernia]

6. Orchidectomy

Following reduction of the hernia sac, the spermatic cord was traced into the inguinal canal up to the deep (internal) inguinal ring.

Radical inguinal orchidectomy technique (for malignancy):

The spermatic cord was cross-clamped at the level of the deep inguinal ring before any scrotal manipulation to prevent tumour dissemination
A soft clamp was applied at the internal ring as a temporary vascular occlusion
The testis was then delivered from the scrotum into the inguinal wound by gentle traction, dissecting in the extravaginal plane through the scrotum
The gubernaculum was divided with electrocautery
The cord structures were divided in two bundles at the level of the deep inguinal ring: the vas deferens was ligated separately with 2-0 silk, then the vascular bundle (testicular artery and pampiniform plexus) was doubly ligated with 0-silk suture ties and divided
The testis, epididymis, and cord were removed en bloc as a single specimen
The cord stump was allowed to retract through the internal ring into the retroperitoneal space
Haemostasis of the cord stump was confirmed before the clamp was released

Simple orchidectomy (for benign/non-viable testis):

The testis was delivered from the scrotum into the wound
The cord was divided at or near the internal ring, doubly ligated with 0-silk and divided
Specimen removed

Specimen: Left testis, epididymis, and spermatic cord - sent for histopathology / macroscopic inspection confirmed [describe findings].

7. Haemostasis and Scrotal Check

Haemostasis of the cord stump, gubernacular remnants, and scrotal bed was confirmed with electrocautery. The scrotum was gently compressed to evacuate any haematoma. No active bleeding was noted.

8. Lichtenstein Mesh Repair (Hernioplasty)

A piece of flat polypropylene mesh (lightweight/standard, 6 x 11 cm or standard Lichtenstein size) was trimmed and fashioned to fit the inguinal canal floor.

Steps:

A longitudinal slit was cut into the distal lateral edge of the mesh to create two tails to accommodate the now-absent spermatic cord stump (or residual cord if preservation warranted)
The periosteum overlying the pubic tubercle was exposed and cleared medially for at least 2 cm - the mesh was not sutured directly into the periosteum to minimise chronic pain and osteitis
The inferomedial edge of the mesh was sutured to the shelving edge (Poupart's ligament) beginning just medial to the pubic tubercle using a continuous 0-Prolene (polypropylene) suture, running laterally and superiorly to a point just lateral to the internal inguinal ring, where it was tied
The mesh overlapped the pubic tubercle by at least 2 cm medially
Interrupted 2-0 Prolene sutures were placed to secure the superior edge of the mesh to the conjoint tendon (internal oblique/transversus abdominis aponeurosis), taking care not to entrap the ilioinguinal or iliohypogastric nerves
The two tails of the mesh were arranged to reconstruct (or close) the internal inguinal ring around the cord stump (or cord) and sutured together with a single 2-0 Prolene suture, creating a snug but not constrictive neo-ring
Any excess mesh was trimmed; the mesh lay flat without bunching or folding

Mesh used: [Brand, type, size e.g. Bard Mesh 6x11 cm flat polypropylene]

9. Nerve Preservation Check

All three nerves - iliohypogastric, ilioinguinal, and genital branch of the genitofemoral nerve - were re-identified and confirmed to be free of entrapment by sutures or mesh edges. Any nerve crossing the mesh was repositioned over the mesh surface or protected with a slit in the mesh.

10. Wound Closure

The external oblique aponeurosis was re-approximated over the cord remnant/reconstructed canal with a continuous 2-0 Vicryl suture down to and reconstructing the superficial inguinal ring (ensuring it was not too tight)
Scarpa's fascia was closed with interrupted 2-0 Vicryl
Subcutaneous tissue was closed with 2-0 Vicryl
Skin was closed with subcuticular 3-0 Monocryl (or staples / interrupted nylon)
Wound dressing applied

11. Drain Placement

A drain was not routinely placed. A closed-suction drain may be placed if:

Significant haematoma risk from orchidectomy bed
Extensive dissection performed
[If placed: specify type, exit site]

Intraoperative Findings

Structure	Finding
Hernia type	Left indirect / direct / pantaloon
Hernia sac contents	Empty / omentum / small bowel (viable)
Sac size	[cm]
Testis (macroscopic)	[e.g., Atrophic; hard nodule; necrotic; normal apart from hernia; tumour on cut section]
Epididymis	[Normal / abnormal]
Cord	[Normal calibre / thickened / lipoma present]
Inferior epigastric vessels	Identified and preserved
Nerves (ilio-inguinal, iliohypogastric, genitofemoral)	Identified and preserved

Specimens Sent

Left testis + epididymis + spermatic cord - histopathology (urgent / routine)
Hernia sac - histopathology (if indicated)

Estimated Blood Loss

[e.g., <100 mL]

Postoperative Instructions

Analgesics: regular paracetamol + ibuprofen (NSAIDs if not contraindicated); opioid PRN
Scrotal support / jockstrap for 2-4 weeks to reduce swelling
Ice packs to groin/scrotum (20 min intervals) for first 48 hours
DVT prophylaxis: LMWH + mobilisation
Light activity for 2 weeks; avoid heavy lifting/straining for 6 weeks
Wound review at 7-10 days
For testicular malignancy: post-orchidectomy tumour markers (AFP, hCG) at 1 week and 4 weeks; MDT/oncology referral for staging and adjuvant treatment planning
Counsel regarding absent testis; offer testicular prosthesis if desired (may be placed at same sitting or deferred)

Complications to Counsel Preoperatively

Complication	Notes
Haematoma (groin or scrotum)	Most common; reduces with scrotal support
Wound infection	~1-2% with mesh
Mesh infection	Rare (<1%); may require mesh removal
Chronic groin pain (neuropathic)	Up to 10-30%; ilioinguinal/genitofemoral nerve injury
Hernia recurrence	<1-2% with Lichtenstein vs ~3.8x higher with tissue repair
Vas deferens injury	Risk of infertility (especially in contralateral orchidectomy)
Seroma	Particularly if large hernia sac; usually resolves spontaneously
Loss of testis	Inherent to orchidectomy; infertility counselling
Tumour upstaging / altered lymphatics	If scrotal approach used erroneously for malignancy
DVT / PE	Standard surgical risk

Notes on Technique Variations

Post-orchidectomy mesh repair: With the cord absent, the reconstructed internal ring is closed more tightly; the mesh tails can be sutured edge-to-edge after the cord is removed to create a small neo-ring or the ring can be simply closed
Sliding hernia: If bowel forms part of the hernia sac wall, reduce carefully without opening the bowel; partial excision of the sac only
Contaminated field: If bowel was necrotic (strangulated hernia) or frank infection is present, mesh implantation is contraindicated - use a tissue-based repair (Shouldice or Bassini) and stage the mesh repair if needed
Lipoma of the cord: Identified and excised routinely to prevent recurrence

Sources:

Maingot's Abdominal Operations, Operative Techniques (Open Inguinal Hernia Repair), p. 147-152
Sabiston Textbook of Surgery (21st ed.), Tension-Free Anterior Inguinal Hernia Repair, p. 1688
Schwartz's Principles of Surgery (11th ed.), Inguinal Hernia, p. 1771
Sabiston Textbook of Surgery (21st ed.), Treatment of Testicular Cancer (Radical Orchiectomy), p. 2839
Bailey and Love's Short Practice of Surgery (28th ed.), Inguinal Hernia, p. 1269

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