Open Cholecystectomy, Lysis of adhesions
At a loss for CPT codes, help please. Searched 47600 and/or 44145 ???
PREOPERATIVE DIAGNOSIS: Cholecystitis.
POSTOPERATIVE DIAGNOSIS: Gallbladder cancer.
1. Laparoscopic converted to open cholecystectomy.
2. Lysis of adhesions.
3. En-bloc resection of gallbladder tumor including a right hemicolectomy.
4. Choledochotomy with T-tube placement.
SPECIMENS: Include en bloc resection of gallbladder tumor and right colon.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room and placed in the supine position. General endotracheal anesthesia was established, and the abdomen was then prepped and draped in the standard fashion.
The procedure began with a curvilinear supraumbilical incision that was carried through the subcutaneous tissues to the fascia and the fascia at the base of the umbilicus. The umbilicus was then grasped and elevated and an incision was made through the fascia. A heavy Vicryl was placed on either side of this incision. There was significant amount of omental adhesions at the entry and given the amount of bleeding that was incurred through placement of the port and that there was minimum visibility, the decision was made to convert to an open procedure.
A subcostal incision was then made and carried through to the subcutaneous tissues, the fascia and the muscle walls until the abdomen was entered. Of note, even in the right upper quadrant there were a significant amount of omental adhesions. The falciform ligament was transected and divided and the gallbladder was identified by palpation and examined. There was a wedge of omentum adherent to the entire gallbladder and palpation of the liver noted a firm mass. It appeared to be large and involve most of the gallbladder. The hepatic flexure of the colon was attached to the omentum that surrounded the gallbladder and the dissection initially began in this region. Further evaluation of the colon's placement noted that a small segment of the colon was actually adherent to this mass. Given the concern for cancer and the amount of adhesive colonic disease, decision was made to perform a formal right hemicolectomy and add this as an en bloc specimen.
The cecum was then identified and dissected from the surrounding tissues along the white line of Toldt. It was then mobilized medially and the terminal ileum was identified. Of note, the terminal ileum was significantly adhesed into the pelvis and there was at least 30 minutes of lysis of adhesions necessary to free the distal ileum to allow for an appropriate proximal segment of resection. The bowel was then divided using a linear cutting stapler and the mesentery was divided using the LigaSure device. The ileocolic vessels were oversewn with a 3-0 silk. The colon was then divided at the proximal end of the transverse colon and allowed to be attached to the gallbladder.
The decision was made to postpone the anastomosis until the specimen had been removed to allow the bowel to be packed away for better visualization. An extensive Kocher maneuver was performed to free the duodenum and the duodenum was then carefully dissected from the transverse colon. Per the CT scan it did appear to have been thickened but this portion did not appear to be involved in the mass. The stomach was examined, although the pylorus and antrum of the stomach had been identified as thickened they did not appear to be involved in this mass. The stomach and proximal jejunum were then dissected away from the mass with what appeared to be a short segment of inflammatory reaction in the stomach, which peeled easily from the mass.
Attention was then turned towards the liver, which was palpated and noted to be thickened. The decision was then made to perform a non-anatomic wedge resection of the involved liver. The capsule of the liver was scored with electrocautery and the parenchyma divided using a combination of finger fracture and stapling. The exposed biliary ducts were individually clipped and divided. At this point, the gallbladder was able to be visualized separately from the porta hepatitis and through careful dissection, the cystic artery was identified and divided, and the cystic duct was then identified and divided. The mass appeared to be adherent to the common bile duct and was gently shaved off of the bile duct with some deserosalization of the common duct. Decision was made to place a T-tube to this injured area to maintain patency and prevent stricture.
A choledochotomy was then performed using an 11 blade and expanded with Potts scissors. T-tube was then placed through the ductotomy and a confirmatory T-tube cholangiogram was performed and with good visualization down to the duodenum and along the hepatic ducts bilaterally. The T-tube was then brought out through a separate stab incision in the abdominal wall and placed to direct drainage. At this point, the mass could be completely dissected from the common duct porta hepatitis and the stomach and was then passed off the field as a specimen. Hemostasis in the liver was maintained using argon electrocautery and SurgiSeal. The abdomen was then copiously irrigated and examined for hemostasis. An NG tube was then placed post-pyloricically using direct palpation. Attention was then returned to the ileum and colon where an ileocolic anastomosis was performed using a staple technique.
The mesentery was then closed using a running 3-0 Vicryl. The abdomen was again examined for any other evidence of peritoneal spread and none was found. The abdomen was copiously irrigated again with warm sterile normal saline. The subcostal incision was then closed in layers using 0 Prolene. The umbilical fascial defect was closed with 0 Vicryl. Skin was closed with staples. Dressings were then applied.