Laparoscopic Appendectomy
Acute appendicitis
Acute uncomplicated appendicitis
Laparoscopic appendectomy
[***, MD/DO]
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male / female] with clinical and imaging findings consistent with acute appendicitis. The risks, benefits, and alternatives to laparoscopic appendectomy were discussed, and informed consent was obtained.
The appendix was [mildly / moderately / markedly] inflamed without perforation or abscess. The appendiceal base and adjacent cecum were viable.
The patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.
The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established via [open Hasson technique / optical trocar / Veress needle]. A 12-mm umbilical trocar and 5-mm suprapubic and left lower quadrant trocars were placed under direct visualization.
The patient was positioned in Trendelenburg with left lateral tilt. The cecum was identified, and the taeniae were followed to the appendix. The appendix was elevated, and the base and adjacent cecum were inspected and found suitable for division. The mesoappendix was divided with [an energy device / an endoscopic linear stapler / clips], controlling the appendiceal artery.
The appendix was divided at its base with [an endoscopic linear stapler / two proximal endoloops and one distal endoloop]. The specimen was placed in an endoscopic retrieval bag and removed through the umbilical port. The appendiceal stump and mesoappendix were inspected and were intact and hemostatic.
Any residual fluid in the right lower quadrant was suctioned. The operative field was inspected, and hemostasis was confirmed. The trocars were removed under direct visualization. The fascia at the 12-mm port was closed with [0-Vicryl], and the skin was closed with [4-0 Monocryl]. Sterile dressings were applied.
None
Appendix sent to pathology
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Acute appendicitis
POSTOPERATIVE DIAGNOSIS: Acute uncomplicated appendicitis
PROCEDURE PERFORMED: Laparoscopic appendectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with right lower quadrant pain and imaging consistent with acute appendicitis. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
FINDINGS: The appendix was inflamed without perforation or abscess. The appendiceal base and adjacent cecum were viable.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, operative procedure, operative site, allergies, and administration of prophylactic antibiotics per protocol.
The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established via [open Hasson technique / optical trocar / Veress needle]. An umbilical trocar and suprapubic and left lower quadrant trocars were placed under visualization. The patient was positioned in Trendelenburg with left lateral tilt.
The cecum was identified, and the taeniae were followed to the appendix. The base and adjacent cecum were viable. The mesoappendix was divided with ***, controlling the appendiceal artery. The appendix was divided at its base with ***. The specimen was placed in a retrieval bag and removed through the umbilical port. The appendiceal stump and mesoappendix were intact and hemostatic.
Residual fluid was suctioned, and hemostasis was confirmed. The fascia at the 12-mm port and the skin incisions were closed. Sterile dressings were applied.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Appendix to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Perforated Appendicitis
The appendix was perforated at [the tip / the body] with [purulent / feculent] contamination involving the [right lower quadrant / pelvis / right paracolic gutter / multiple quadrants]. Contaminated fluid was suctioned, and the appendix was resected at a viable base. Irrigation [was not performed / was performed with warm saline and the irrigant was suctioned]. A drain [was not placed / was placed in the right lower quadrant because ***].
Necrotic Base / Partial Cecectomy
The appendiceal base was [necrotic / perforated / gangrenous], and the adjacent cecal wall was too friable for division at the base. An endoscopic linear stapler was applied across healthy cecal tissue beyond the diseased segment, completing a limited partial cecectomy. The staple line was intact and hemostatic. A drain [was not placed / was placed adjacent to the staple line because ***].
Converted to Open
Because of [dense adhesions / inability to expose the appendix safely / bleeding / uncertain anatomy], the procedure was converted to an open approach through a [right lower quadrant transverse / lower midline] incision. The appendix was exposed, the mesoappendix was ligated and divided, and the appendix was divided at a viable base. The stump and operative field were inspected, and the incision was closed in layers.
Charting Tips
- Describe the appendix as uncomplicated, gangrenous, or perforated and record any abscess or gross contamination. These findings influence postoperative management and reimbursement.
- Document appendiceal-base and adjacent-cecal viability, the method of stump closure, and the final integrity of the stump or staple line.
- For complicated appendicitis, record the distribution of contamination, whether suction alone or suction with irrigation was used, and the reason for any drain placement.
Documentation & Reimbursement Considerations
- Report Laparoscopic Appendectomy as the primary service when it is the definitive operation performed.
- Use for uncomplicated acute or chronic appendicitis removed laparoscopically.
- Document frank perforation, feculent contamination, extent of peritoneal involvement, and washout performed.
- 90-day global period applies. Drain management and wound checks within 90 days are bundled unless a separately identifiable service is provided.
- If a concurrent procedure is performed (e.g., lysis of adhesions, enterotomy repair), append multiple-procedure reporting and document each procedure separately in the operative note.