Introduction: Concerns have been raised as to how to maintain pictorial documentation of an interesting finding during laparoscopic cholecystectomy (LC). We believe that documentation of surgery is of essential benefit, especially if a complication arises. In addition, documentation may be utilized for future reference for patient care.
Methods: We reviewed the pictorial documentation of 100 cases of LC. Our standard of practice is to keep eight pictures per frame during a LC. These pictures describe the critical points during the procedure. Occasionally, due to some interesting findings, additional pictures are taken. These pictures serve as an essential guide for proper management of patients when presenting with post-operative complaints. We believe the first picture must be the way the gallbladder was initially identified with/without adhesions to correlate the symptoms with the operative findings. Next, management of the cystic duct as well as the cholangiogram itself are photographed. Then, the occlusion and division of the cystic artery and liver bed evaluation are photographed. Finally, we document whether the gallbladder was removed entirely without perforation, as well as the process of extraction.
Results: There were no intraoperative complications that were noted in the last 100 patients that we have seen. Nine patients required an additional post-operative office visit did well without any further testing because of the pictorial documentation of the LC. This led us to believe that the documentation of the pictures helped with early post-operative period complaints, thus saving health care money and aiding patient care. One patient required an ERCP with stone extraction. The intervention was carried out promptly because of the advantage of pictorial documentation. Finally, when patients continue to have similar pain after LC, the documentation of the initial operative findings of the gallbladder with/without adhesions are of insurmountable value for future medical management.
Conclusions: Proper, important, pictorial documentation should be saved and used as a future reference in clinical settings like lab data and x-ray findings. We described eight essential steps of pictorial documentation in a LC that are of significant value for patients with post-operative follow-up. Proper management can be initiated in the early post-operative period in cases where a complication arises because of access to actual operative findings.
Program Number: P551