# Open cholecystectomy with a common bile duct exploration with choledochoscopy and T-t



## bda23054 (Nov 27, 2012)

I could use some help coding this procedure, THANKS:

NAME OF OPERATION
Open cholecystectomy with a common bile duct exploration with choledochoscopy and T-tube placement.

INDICATIONS 
This was an 87-year-old male who has had a know history of cholecystitis but started developing significant jaundice.  Dr. Byrne had done an ERCP to evaluate the jaundice and noted multiple common bile duct stones and evacuated as many as possible, but he noted there were several that he could not evacuate.  The patient had multiple medical conditions and was high risk for the surgery, but despite this we saw no other viable option.  

DESCRIPTION OF OPERATION
The patient was placed in the supine position.  General endotracheal anesthesia was induced.  Preoperative antibiotics were given and Foley catheter and nasogastric tubes were placed.  The abdomen was prepped and draped in the usual sterile fashion.  A right subcostal incision was made 2 fingerbreadths below the costal margin and extended from just to the right of the xiphoid to the anterior axillary line.  this was deepened through the subcutaneous tissues and hemostasis was achieved with electrocautery.  The fascial and aponeurotic layers of the abdominal wall were divided with electrocautery, and the peritoneal cavity was entered.  Falciform ligament was doubly ligated with a 2-0 silk and divided.  The abdomen was explored.  There was noted to be dense adhesions within the right upper quadrant.  Lysis of adhesions of greater than an hour were done to finally identify the gallbladder, but the gallbladder was then evaluated and the peritoneum overlying Calot triangle was attempted to be dissected, what was thought to be the cystic duct was identified and encircled with clips on the distal end on what was thought to be the cystic duct.  Cholangiocatheter was then inserted and cholangiograms were obtained revealing multiple filling defects within the distal common bile duct.  The previously placed stent by Dr. Byrne was identified but nothing into the intrahepatic ducts.  This area was then ligated completing the cholecystectomy.  At this point, it was after resection of this area, there was noted that there was some bile leaking from the cephalad area concerning for common bile duct area.  Cholangiogram was then inserted in this area and found the gallbladder must have been adhesed because we were in the common bile duct.  The Kocher maneuver was then performed incising the peritoneal attachments lateral to the duodenum and gently rotating the duodenum and head of the pancreas medially.  The common duct and the head of the pancreas were palpated and found to have large stones within the common duct.  The peritoneum overlying the common duct was then incised and attention was then turned to where we had previously resected the gallbladder.  The incision within the common bile duct was enlarged.  Common bile duct stones at this point were gently milked from the distal duct and emerged from the choledochotomy, where they were retrieved.  Fogarty catheter was then passed proximally and distally and stones again were retrieved.  Common bile duct was irrigated proximally and distally until no debris was obtained.  Attempt was then made to pass a choledochoscopy through the ampulla which was successful.  When all stones had been retrieved, a cholangiogram was performed and noted to have contrast within the duodenum and proximally into the common hepatic.  An 8-French T-tube was then placed in the common duct and the choledochotomy was then closed using a 4-0 PDS suture in a continuous fashion above and below the T-tube.  Closure was tested with saline and a single figure-of-8 PDS was used to complete the closure of the choledochotomy.   Air was then expelled from the T-tube.  A completion cholangiogram was then obtained under fluoroscopic guidance.  Contrast did enter the duodenum.  No stones were noted.  The T-tube was then brought along the inferior border of the liver medially and out through a separate inferior incision inferior to the subcostal incision.  Closed suction drain was placed in the subhepatic space and brought out through a separate skin incision lateral to the T-tube.  The T-tube was sewn to the skin with consideration slack in the tubing. Both drains were affixed to the abdominal skin using 3-0 nylon suture.  Hemostasis was checked.  The field was irrigated and omentum was placed over the choledochotomy.  Incision was closed in layers with an 0-Vicryl for the peritoneal layer, 3-0 chromic for the muscle layer, 0-PDS for the anterior fascial layer, and then skin staples.  The T-tube drain was placed to gravity, the JP-drain was closed with closed suction bulb, Provena wound V.A.C. system was placed.  The patient tolerated the procedure adequately, and transferred to Intensive Care Unit in guarded condition.


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## tcooper@tupelosurgery.com (Nov 27, 2012)

I think that you would use the 47610 and the 47550(add on code)...Please look at the explanation under the 47610 code in the CPT book. I hope this helps..
Teresa


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## bda23054 (Nov 27, 2012)

Reading the description now!  Thank you.


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