# HELP!! Cholecystoduodenal fistula



## ksrkelly7 (Jan 18, 2017)

Hi there.  Any help with this OP report would be greatly appreciated.  

Doc wants to bill CPT 47563-22 and 44603 

 I see the 47563 but not sure what to do about the duodenotomy or repair of cholecystoduodenal fistula.  I don't see 44603.  I thought about an unlisted code laps code, 44238, with 44010 as a comparable code, but not sure that fits either.  HELP!!


Indication for Surgery 
Persistent drainage

Preoperative Diagnosis 
Cholecystocutaneous fistula

Postoperative Diagnosis 
Cholecystocutaneous and cholecystoduodenal fistulas.  Chronic cholecystitis

Operation 
Laparoscopic cholecystectomy, repair of cholecystoduodenal fistula


Findings 
There were extensive omental adhesions to the anterior abdominal wall and the liver as well as to the gallbladder.  There did appear to be a fistula between the gallbladder and the anterior abdominal wall.  There was also a fistula between the duodenum and the gallbladder.  The cholangiograms were normal.                                                                                                              

Specimen(s) 
Gallbladder and stones

Complications 
none

Technique 
After pre-operative evaluation and informed consent was obtained, the patient was brought to the operating room.  She was placed under suitable general anesthesia with endotracheal intubation.  Sequential compression devices were applied.  IV antibiotics were administered.  A surgical pause was performed to confirm the patient identification and correct surgical procedure.   The patient was then prepared and 3 minutes of drying time for the prep was allowed prior to draping the patient in the usual sterile fashion.

 A supraumbilical stab wound incision was made and a 5 mm Optiview port was placed through this into the abdominal cavity without complication.  The abdomen was insufflated with CO2 to a pressure of 15 mm Hg.   The 30 degree videolaparoscope was inserted and the abdomen was examined with the above noted findings.  An additional 5 mm port was placed in the left upper quadrant under direct vision and without complication.  The omental adhesions to the anterior abdominal wall and round ligament were lysed using the Ligasure device.  The omental adhesions to the liver were also lysed using the Ligasure device.  There was a tubular pseudocapsule found extending between the anterior abdominal wall and to a fully sized gallbladder.  The gallbladder was grasped and retracted towards the right hemidiaphragm after this fistulous tract was divided with the Ligasure device.   An additional 5 mm port was placed in the right upper quadrant, through her old scar.  A 10 mm port was placed in the epigastrium under direct vision and without complication through her old scar as well.  .  The omental adhesions were dissected away from the gallbladder using blunt dissection and the Ligasure device.  The stomach was visualized and the duodenum was found to be adherent to the gallbladder close to the neck.  Careful dissection was performed and the duodenum was found to be fistulized to the gallbladder.  This connection was divided sharply.  The duodenotomy was closed using laparoscopic suturing technique in 2 layers with 2-0 Vicryl suture.  The attention was returned to the gallbladder. The gallbladder neck/cystic duct junction was identified.  The cystic duct was further dissected freely proximally.  The gallbladder neck/cystic duct junction was endoclipped and the cystic duct was opened.  A Cook cholangiocatheter was inserted and cholangiograms were obtained with the above noted findings.  The cholangiocatheter was removed and the cystic duct was doubly endoclipped and divided between the clips.  The cystic artery was sealed with the Ligasure device and divided.  The gallbladder was then dissected away from the liver bed using the Ligasure and the electrocautery device.  The gallbladder contained very large gallstones.  The gallbladder was placed into an endocatch specimen retrieval bag and removed through the 10 mm port site.  The subhepatic and subphrenic spaces were copiously irrigated with saline solution.  There was excellent hemostasis.  A 19 French Blake drain was placed in the subhepatic space and brought out through the left upper quadrant port site.  This was sutured to the skin using 3-0 Nylon suture.  The ports were removed under direct and there was no bleeding from these sites as well.  The epigastric fascial defect was closed using 0-PDS suture.   The skin incisions were closed using 4-0 Monocryl suture.  Dermabond was applied.  The previously draining site was cauterized with the electrocautery device.  Betadine was used to irrigate this as well.   A dry gauze dressing was applied.  A drain sponge was placed around the drain exit site.  The patient was awakened out of anesthesia, extubated and transported to the recovery room in fair condition.                                  

Thanks for your help!

Kelly-C, CPC


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