# Expl lap with control of biliary leak



## lcathey@smsc.org (Jul 18, 2013)

Need help with this one.  Dr. used cpt 49002 and 47900, but i'm not sure this is correct and the hospital cross code is 51.71 which crosses over to 49999.   She is also in post op for lapchole, and distal gastrectomy/loop gastrojejunostomy by a different surgeon. I would appreciate any suggestions:


PREOPERATIVE DIAGNOSIS:

Abdominal pain. 




POSTOPERATIVE DIAGNOSES:

1. Abdominal pain. 




2. Bile peritonitis, secondary to biliary tract leak. 




PROCEDURES PERFORMED: 

1. Central line placement. 




2. Exploratory laparotomy with control of biliary leak and washing out of the  abdomen. 




SPECIMEN: 

None. 




FINDINGS: 

The patient was found to have bile in her abdomen immediately upon attempt to  place a Hasson trocar for her laparoscopy, so no laparoscopy was done and she  was converted to a laparotomy. She had about 15 to 1800 mL of bile in her  abdomen with multiple areas of bile exudate on loops of bowel. Her anastomosis  at the gastrojejunostomy appeared intact without leakage. There was no abscess.  It appeared that her leak was coming at the base of her cystic duct. This was  oversewn with control of the leak and a cholangiogram was done, as described  below, that showed no extravasation. 




DESCRIPTION OF PROCEDURE: 

Upon induction of adequate anesthesia, the patient already had an NG tube and a  Foley catheter. SCDs had been in already been in place and Lovenox had already  been injected. I prepped and draped the left chest and, in the usual fashion,  accessed the left subclavian vein and placed a triple lumen central line. I had  good venous return. It was secured and dressed. 




At this point, we then prepped and draped her abdomen. I used a Hibiclens wash,  followed by alcohol, followed by a clear sticky drape. I made a small incision  just above her umbilicus and, in the open fashion, went to place a Hasson  trocar, but upon entering the peritoneal cavity, a significant amount of bile  came out. At this point, I knew that we had a bile leak to go after and did not  feel that laparoscopy was the appropriate choice. I made an upper midline  incision and, in fact, went from the sternum to the midpoint beneath her  umbilicus and immediately aspirated out approximately 15 to 1800 mL of bile. 




The first thing I did was check her gastrojejunostomy. That anastomosis was  intact without any evidence of leakage. I ran her small bowel and found no  other problems. I went ahead and then lifted up the liver and began some blunt  dissection down to where her cystic duct stump was. I could not get to the  duodenal stump as it was encased in some inflammatory tissue and I did not want  to dissect down, if I did not have to, to that. When we spent time looking at  her cystic duct stump area, we finally found a small leak at the base of her  cystic duct stump. I took the clip off that had been previously placed, and I  oversewed this stump with a couple of 4-0 figure-of-eight Vicryl sutures. We  then irrigated that subhepatic space well and found no further biliary leak. 




At this point, I took a 25-gauge butterfly needle and after several attempts  was able to access the common hepatic duct. I then injected contrast and, under  fluoroscopy, could see that the bile flowed briskly into her duodenum with no  duodenal stump leak, no extravasation out of the oversewn areas, and no other  pathology, particularly no cramping of her common bile duct from my oversewing.  With this completed, we irrigated that area well and then began a systematic  4-quadrant irrigation of the abdomen, peeling off inflammatory exudate off  multiple areas of small bowel. With this completed and no other pathology  noted, I placed a Blake drain underneath her subhepatic space on the right,  covering that bile leak repair. Then I placed another Blake drain in the left  upper quadrant up underneath the left hemidiaphragm. These were secured at the  skin level with silk.




Then I went ahead and closed the fascia with interrupted #1 Vicryl Plus sutures  with interspersed #1 Prolene sutures and then infiltrated the wound with  Marcaine, irrigated it out well. With no bleeding noted, I then closed the  subcutaneous layer with interrupted 3-0 Monocryl sutures and the skin with  staples and a dressing. The drains were dressed. The central line site was  dressed, and the patient was transported to the intensive care unit intubated  but in stable condition. Final needle and sponge counts were correct.


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