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Anybody want a challenge?

  1. #1
    Default Anybody want a challenge?
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    I know this is a little long.... anybody want to give it a try???

    A laparoscope was inserted and manipulated around some filmy omental adhesions secondary to prior surgery, and the right upper quadrant structures are visualized. There is significant omental fat which is adherent to the body of the gallbladder, and this is dissected away to reveal an acutely inflamed, thick walled, distended gallbladder. Laparoscopic needle was used to deflate the gallbladder so it could be grasped with forceps and elevated toward the patient's right shoulder. There is tremendous inflammation in the area of the neck of the gallbladder and the infundibulum is distended with hard stones. Carefully the fatty tissues dissected away from the neck and a short but otherwise normal-appearing cystic duct is isolated and clipped close to the gallbladder. A second clip was placed about a centimeter away, and the duct is divided. A large inflammatory lymph node rests just superior to the cystic duct so the identification and dissection of the cystic artery somewhat difficult. This is done by gently removing the lymph node and cystic artery is doubly clipped and divided as well. This mobilizes the neck of the gallbladder and careful blunt dissection and electrocautery are used to free up the neck. There was however a third tubular structure that is identified on the back surface of the neck of the gallbladder. It looks about the same size as the cystic duct, but seems to be disappearing into the gallbladder as well. This is also clipped and divided and this is done close to the gallbladder wall. The gallbladder is then dissected away from its hepatic bed with combination blunt dissection and electrocautery. There is dense inflammatory tissue and reactive soft tissue in the area which makes this dissection somewhat difficult, but finally the gallbladder is removed totally from the liver bed and transferred to a large grasping forcep at the upper midline trocar site. Attempts to remove the gallbladder were unsuccessful however because the thickening of the infundibulum of the gallbladder and the presence of stones there median possible to deliver the neck of the gallbladder outside the abdomen. Passages of stone forceps into the gallbladder were unsuccessful and breaking up removing any stones, but portions the gallbladder wall were finally delivered piecemeal. Finally we were able to open the gallbladder inside the abdomen and see a large, round, hard stone measuring about 2-1/2 cm in size which still remained in the lumen of the gallbladder. Attempts were made to grasp it, break it up, deliver it, all to no avail and the stone was finally grasped with the large claw forceps and broken into several large pieces. These pieces were put back in the gallbladder is then delivered to the trocar site and the pieces of stone were extracted singly until the rest of the gallbladder could be removed. This whole process took almost an hour. Finally, we were able to reinsert the trocar and copiously irrigate and suction the right upper quadrant. There had been some oozing blood but no obvious bleeding was noted. Surgeons made in the area of the porta for any aberrant anatomy, but the inflammation and edematous tissue in the area made it impossible to dissect further and identify the common duct. Once the abdomen was irrigated some omental fat was placed in the gallbladder fossa and procedure was terminated

  2. Default
    Too bad ASC's can't use -22 modifiers......

    I didn't spend enough time researching this but have you looked at 47564?

  3. #3
    Athens, OH
    I was also going to suggest the 47564.
    RBoggs CMA, CGSC **Bloom where you are planted**

  4. #4
    Yes I was looking at that specifically, but was not 100% sure. I thought having other eyes on the note would help.

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