4042F Documentation that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor given intraoperatively (PERI 2)

Name of the Procedure:

Laparoscopic Cholecystectomy (Gallbladder Removal)

Summary

A minimally invasive surgical procedure to remove the gallbladder using small incisions and a laparoscope. This is often recommended for patients with gallstones or gallbladder inflammation.

Purpose

This procedure is performed to treat gallstones, gallbladder inflammation (cholecystitis), and other related conditions. The goal is to alleviate pain, prevent complications, and improve digestive function.

Indications

• Severe, recurrent episodes of gallstone attacks causing pain.
• Acute or chronic cholecystitis.
• Biliary colic.
• Gallbladder polyps or inflammation.
• Bile duct obstruction caused by gallstones.

Preparation

• Fast for at least 8 hours before the surgery.
• Adjust routine medications as directed by the healthcare provider.
• Preoperative blood tests and imaging studies like an ultrasound or CT scan of the abdomen.

Procedure Description

1. The patient is placed under general anesthesia.
2. Four small incisions are made in the abdomen.
3. A laparoscope (a long, thin camera) is inserted through one incision.
4. Surgical instruments are introduced through the other incisions.
5. The gallbladder is carefully detached and removed.
6. Instruments are removed, and the incisions are closed with sutures or staples.

Duration

The procedure typically takes 1 to 2 hours.

Setting

Performed in a hospital or an outpatient surgical center.

Personnel

• Surgeon
• Anesthesiologist
• Surgical nurse
• Scrub technician

Risks and Complications

• Infection
• Bleeding
• Injury to nearby organs (e.g., bile duct, intestines)
• Blood clots
• Anesthesia-related complications

Benefits

• Relief from pain and discomfort caused by gallstones.
• Reduced risk of gallbladder-related complications.
• Quick return to normal activities compared to open surgery.
• Minimal scarring due to smaller incisions.

Recovery

• Post-procedure: Observation in a recovery room until the anesthesia wears off.
• Pain management with prescribed medications.
• Instructions on wound care and activity restrictions.
• Follow-up appointment with the surgeon.
• Full recovery is typically within 1 to 2 weeks.

Alternatives

• Medication to dissolve gallstones (less effective and slower).
• Open cholecystectomy (larger incision and longer recovery).
• Watchful waiting for asymptomatic gallstones.

Patient Experience

• Mild to moderate pain and discomfort in the abdomen post-surgery.
• Possible nausea or bloating temporarily.
• Gradual improvement in symptoms and daily activities within a few days.
• Regular follow-up for monitoring and addressing any complications.

Note: In this specific case, it's documented that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor given intraoperatively (PERI 2). This deviation from standard protocol should be reviewed and justified based on the patient's condition and surgical context.