# open cholecystectomy, intraop cholangiogram, ligation- bleeding vasculature of portal



## ksb0211 (Sep 20, 2011)

Just wanted some other opinions on this one.  I willl list my thoughts after the op report.  Thanks.

PREOPERATIVE DIAGNOSIS
Cholelithiasis, cholecystitis.

POSTOPERATIVE DIAGNOSIS
Cholelithiasis, cholecystitis, choledocholithiasis, abscess of liver, severe bleeding from the hepatic bed.

OPERATION PERFORMED
Attempted laparoscopic cholecystectomy with open cholecystectomy, intraoperative cholangiogram, ligation of bleeding vasculature of portal area with intraoperative cholangiogram.

SURGEON
XXXXX
FIRST ASSISTANT
YYYYYY

ANESTHESIA
General.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR after induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely.  The skin was incised in the infraumbilical region with a #15 blade and carried down through the subcutaneous tissues.  A Veress needle was introduced.  The abdomen was insufflated to 15 mmHg of pressure with CO2.  Once this was done, the OptiView port was passed without difficulty.  Circumferential view of the peritoneal cavity was noteworthy in that the gallbladder actually could not be seen.  There was adhesion.  The 5 mm port was placed in the right upper quadrant and a 10 mm port in the epigastrium.  The gallbladder was not well seen, but with continued effort  I was able to take down some omental adhesions and it was clear that there was distal stomach or duodenum attached to the liver bed.  Attempts were made to bring this down with dissection and cautery that were unsuccessful.  It was decided at this point that an open surgery would be required.  The right subcostal incision was then made with a #15 blade.  The abdominal wound was opened with electrocautery.  The Bookwalter retractor was placed.  With this completed, the duodenum was taken down from the gallbladder.  Ultimately it was clear that actually it was the pylorus itself which was markedly adherent to the gallbladder.  No injury to the bowel was noted.  Once this was done, the gallbladder was grasped with a Kelly clamp and dissection ensued.  The Harmonic scalpel was utilized as it was somewhat intrahepatic and markedly adherent.  The gallbladder appeared to be small, but I was able to get base of it and to where I thought we would find the cystic duct.  Dissection was continued in the plane between the gallbladder and the hepatic bed with the Harmonic scalpel when abruptly marked bleeding was encountered.  The wound was rapidly packed.  The source of bleeding was not immediately evident.  Dr. YYYYYY was able to assist and ultimately we found that there was significant bleeding from the liver bed, possibly some hepatic radicals.  The bleeding was controlled with interrupted sutures of 4-0 Prolene.  Blood loss was rapid and significant; however ultimately was completely controlled.  The dissection was then resumed on the gallbladder.  It was continued down towards the confluence with the common bile duct.  Ultimately it was appreciated that actually the gallbladder itself was very small and that we were tenting up the common duct.  The gallbladder was opened and attempt was made to trace the distal gallbladder to the cystic duct.  Ultimately we were able to identify the cystic duct and perform intraoperative cholangiogram.  Some minimal extravasation of dye was noted in the portal area and also obstruction of the common duct was noted with the distal common bile duct stone.  With this information, decision was to proceed with common bile duct exploration.  The common bile duct was opened after placing stays of 3-0 silk.  The attempts at utilizing the Fogarty biliary catheter and irrigation were unsuccessful.  Ultimately, we utilize choledochoscope and it was clear that there was in fact a distal common bile duct stone.  The Randall forceps were ultimately utilizing and we were able to crush the stone and the repeat choledochoscopy was negative for residual obstruction.  A 12 French T tube was then placed.  Intraoperative cholangiogram showed that there was no distal obstruction.  The proximal extravasation was thought to be from an area of denuded duct but was relatively minimal and the duct appeared viable.  A Jackson-Pratt drain was then placed.  The wound was thoroughly irrigated with saline solution.  The T tube was secured with interrupted figure-of-8s of 5-0 PDS suture.  It was brought through a separate stab incision as was the 10 mm Jackson-Pratt.  The liver bed was inspected for hemostasis.  The area in question in the hepatic bed was well inspected.   The color of the liver appeared acceptable.  The wound was then closed with running double-stranded PDS to the posterior rectus sheath and similar material to the anterior rectus sheath.  Subcutaneous tissue was closed with 2-0 Vicryl and clips were applied to the skin.   The procedure was prolonged approximately 4-1/2 hours.  The estimated blood loss was 4700 mL.  Foley catheter was placed at the end of the procedure.   He received 6 units of packed cells and 2 units of FFP as well as platelets.  The patient was taken in guarded condition to the recovery room on the ventilator, he will then go to the intensive care unit.

So these are my thoughts although I am obviously not sure of myself.
47610             574.70 & V64.41
47350 -51       998.11(?) & 572.0

Ugh.  I know that 47350 has higher RVU's but since it wasn't really the primary procedure should I just list it second?  I've changed my thoughts on this a few times.  LOL


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