Can anyone help with CPT's for this ????
PROCEDURES:
1. Laparoscopic converted to open cholecystectomy.
2. Intraoperative cholangiogram.
3. Common bile duct exploration.
DESCRIPTION OF PROCEDURE: A curvilinear infraumbilical incision was made and carried through the subcutaneous tissue to the fascia at the base of the umbilical stalk which was then divided. A heavy Vicryl was placed on either side of the fascial defect. The Hasson trocar was then entered in the abdomen and the pneumoperitoneum was established. Examination of the abdomen noted an inflammatory mass in the right upper quadrant with adhesions of the colon to the gallbladder and liver. A 10-mm subxyphoid port was then placed through a separate stab incision. This port was then used to dissect colon from the liver bed. Once the colon had been mobilized, the gallbladder was then able to be identified and two 5-mm right upper quadrant ports were then placed under direct vision. The gallbladder was then grasped and elevated and the peritoneal inflammatory adhesions to the liver, gallbladder and colon were then further debrided so that the gallbladder could be easily identified. Of note, there was a nonmobile firm mass in the fundus of the gallbladder consistent with the previous report of an impacted stone in the gallbladder neck. Circumferential dissection noted a widened tubular structure that was initially thought to be a portion of the body of the gallbladder then was recognized as being potentially a part of the common duct. This was circumferentially dissected and medial and lateral traction of the gallbladder did not identify any other candidates for a cystic duct. As visualization was becoming increasingly poor due to the significant amount of inflammation, the decision was made to perform an intraoperative cholangiogram to better delineate the anatomy. A small incision was then made in the tubular structure and the cholangiocatheter was then introduced. It was clipped into place and cholangiogram was performed. Of note, there was good drainage of the common duct and the duodenum as well as a filling defect immediately distal to the clips consistent with the impacted stone with filling of the gallbladder. There was no cystic duct noted and importantly, there was no evidence of retrograde identification of the hepatic biliary tree. Multiple images were taken and there was no further delineation of the intrahepatic ducts. Given the placement of the stone and the surrounding inflammation, there was significant amount of concern that this tubular structure represent after the common duct and not just support from the gallbladder that were not just support from the gallbladder. An incision was then made at this time to convert to an open procedure to better allow for visualization and safely delineate the patient's anatomy. The pneumoperitoneum was then allowed to resolve. The line between the incisions between the subcostal and subxiphoid incisions were then connected using the scalpel Blade. The incision was then carried through the subcutaneous tissue and the anterior and posterior fascia were then divided with electrocautery. The abdomen was then entered. The pneumoperitoneum was allowed to resolve. The colon was then retracted caudally and the duodenum was then able to be identified. The gallbladder was then fully exposed and dissected free of the surrounding tissue. The gallbladder fossa in a top down fashion. Of note, several visible small ducts were ligated from the bed to the gallbladder. The gallbladder itself appeared to be quite contracted from what appeared to be chronic inflammation. Once the gallbladder above this impacted stone was freed from the gallbladder fossa, an attempt was made to milk the stone distally into the fundus and body of the gallbladder. However, it remained quite stuck. At this point the gallbladder was then divided above the stone and stone forceps were then used to try and retract the stone. After a small amount of difficulty, this was finally able to be performed. In the gallbladder, the stones were passed off the field as specimen. The cystic artery was then identified and medial to this proximal segment of the gallbladder and then divided and ligated. Tracing the gallbladder neck towards the initial choledochoductomy, noted no evidence of connection between the two. Palpation and bringing the common duct more superiorly, the common hepatic duct could therefore be identified. The stump of the gallbladder neck was oversewn using a running Prolene. The initial choledochotomy was then explored, probed, and noted to track both caudally and distally. The choledochotomy was then enlarged with Potts scissors and then flushed.
The common duct was then closed over a 16-French T-tube using interrupted 4-0 Prolene. The end of the T-tube was brought out through the remaining lateral portal incision. A followup T-tube cholangiogram was then performed. At this point the common duct could be successfully elucidated without evidence of spillage of contrast into the abdomen. At this point, a JP drain was then placed through a separate stab incision with the drain at the site of the gallbladder fossa. The abdomen was irrigated with copious terminal normal saline and there was no evidence of ongoing bleeding. The abdomen was then closed with #1 Vicryl in a running fashion to the posterior fascia and peritoneum. Then a second #1 Vicryl was used in a running fashion for the anterior fascia. The umbilical site was then closed with the previously placed heavy Vicryl and then staples were then placed on the remaining incisions to close the skin. The drains were then secured to the skin using 3-0 nylon. Dressings were then applied.
PROCEDURES:
1. Laparoscopic converted to open cholecystectomy.
2. Intraoperative cholangiogram.
3. Common bile duct exploration.
DESCRIPTION OF PROCEDURE: A curvilinear infraumbilical incision was made and carried through the subcutaneous tissue to the fascia at the base of the umbilical stalk which was then divided. A heavy Vicryl was placed on either side of the fascial defect. The Hasson trocar was then entered in the abdomen and the pneumoperitoneum was established. Examination of the abdomen noted an inflammatory mass in the right upper quadrant with adhesions of the colon to the gallbladder and liver. A 10-mm subxyphoid port was then placed through a separate stab incision. This port was then used to dissect colon from the liver bed. Once the colon had been mobilized, the gallbladder was then able to be identified and two 5-mm right upper quadrant ports were then placed under direct vision. The gallbladder was then grasped and elevated and the peritoneal inflammatory adhesions to the liver, gallbladder and colon were then further debrided so that the gallbladder could be easily identified. Of note, there was a nonmobile firm mass in the fundus of the gallbladder consistent with the previous report of an impacted stone in the gallbladder neck. Circumferential dissection noted a widened tubular structure that was initially thought to be a portion of the body of the gallbladder then was recognized as being potentially a part of the common duct. This was circumferentially dissected and medial and lateral traction of the gallbladder did not identify any other candidates for a cystic duct. As visualization was becoming increasingly poor due to the significant amount of inflammation, the decision was made to perform an intraoperative cholangiogram to better delineate the anatomy. A small incision was then made in the tubular structure and the cholangiocatheter was then introduced. It was clipped into place and cholangiogram was performed. Of note, there was good drainage of the common duct and the duodenum as well as a filling defect immediately distal to the clips consistent with the impacted stone with filling of the gallbladder. There was no cystic duct noted and importantly, there was no evidence of retrograde identification of the hepatic biliary tree. Multiple images were taken and there was no further delineation of the intrahepatic ducts. Given the placement of the stone and the surrounding inflammation, there was significant amount of concern that this tubular structure represent after the common duct and not just support from the gallbladder that were not just support from the gallbladder. An incision was then made at this time to convert to an open procedure to better allow for visualization and safely delineate the patient's anatomy. The pneumoperitoneum was then allowed to resolve. The line between the incisions between the subcostal and subxiphoid incisions were then connected using the scalpel Blade. The incision was then carried through the subcutaneous tissue and the anterior and posterior fascia were then divided with electrocautery. The abdomen was then entered. The pneumoperitoneum was allowed to resolve. The colon was then retracted caudally and the duodenum was then able to be identified. The gallbladder was then fully exposed and dissected free of the surrounding tissue. The gallbladder fossa in a top down fashion. Of note, several visible small ducts were ligated from the bed to the gallbladder. The gallbladder itself appeared to be quite contracted from what appeared to be chronic inflammation. Once the gallbladder above this impacted stone was freed from the gallbladder fossa, an attempt was made to milk the stone distally into the fundus and body of the gallbladder. However, it remained quite stuck. At this point the gallbladder was then divided above the stone and stone forceps were then used to try and retract the stone. After a small amount of difficulty, this was finally able to be performed. In the gallbladder, the stones were passed off the field as specimen. The cystic artery was then identified and medial to this proximal segment of the gallbladder and then divided and ligated. Tracing the gallbladder neck towards the initial choledochoductomy, noted no evidence of connection between the two. Palpation and bringing the common duct more superiorly, the common hepatic duct could therefore be identified. The stump of the gallbladder neck was oversewn using a running Prolene. The initial choledochotomy was then explored, probed, and noted to track both caudally and distally. The choledochotomy was then enlarged with Potts scissors and then flushed.
The common duct was then closed over a 16-French T-tube using interrupted 4-0 Prolene. The end of the T-tube was brought out through the remaining lateral portal incision. A followup T-tube cholangiogram was then performed. At this point the common duct could be successfully elucidated without evidence of spillage of contrast into the abdomen. At this point, a JP drain was then placed through a separate stab incision with the drain at the site of the gallbladder fossa. The abdomen was irrigated with copious terminal normal saline and there was no evidence of ongoing bleeding. The abdomen was then closed with #1 Vicryl in a running fashion to the posterior fascia and peritoneum. Then a second #1 Vicryl was used in a running fashion for the anterior fascia. The umbilical site was then closed with the previously placed heavy Vicryl and then staples were then placed on the remaining incisions to close the skin. The drains were then secured to the skin using 3-0 nylon. Dressings were then applied.