# Lap chole converted to lap cholecystostomy



## lmchiatto@yahoo.com (Feb 15, 2016)

Please help!  
Not sure about this one.

Pt was scheduled for a lap chole. Once the doctor started the procedure he states that continuing with the lap chole or even converting to open could result in high risk of bile duct injury so he did a tube cholecystostomy .

I couldn't find a lap cholecystostomy.  I was thinking a 47562 mod 53 with a 48001....?   

here is the op report:

 An infraumbilical curvilinear incision was made just below the umbilicus and dissection carried out down to the fascia.  Traction sutures of 2-0 Vicryl were placed on either side of the midline.  The fascia was incised and the peritoneal cavity was entered without incident.  A blunt-tipped Hasson trocar was placed and the abdomen was insufflated with warm CO2 gas.  Laparoscopy was performed with a 30-degree angled scope. There was no evidence of free fluid or feculent or purulent contamination.  A 12 mm trocar was placed in the subxiphoid midline.  A 5-mm trocars were placed in the right subcostal line in the midclavicular line and a second 5-mm trocar was placed 5 cm caudad and lateral in the anterior axillary line.  The patient was placed in reverse Trendelenburg position and rotated with the right side up.  The liver was gently elevated and the gallbladder was wrapped in omentum and noted to be markedly distended and extremely        
inflamed.  The omentum was gently dissected off of the gallbladder, but was tenaciously adhered.  The edge of the stomach and duodenum were also densely adhered to the gallbladder and the triangle of Calot was not visible and was   
extremely obscured.  For that reason, I felt that laparoscopic cholecystectomy or even open cholecystectomy was associated with the high risk of bile duct injury.  Therefore, the operative management changed from cholecystectomy to tube cholecystostomy.  The gallbladder was aspirated with a needle and approximately 50 mL of clear white bile was obtained.  The bile was submitted to microbiology for culture and sensitivity.  The 5 mm trocar in the right upper quadrant in the midclavicular line was removed and a 12 mm 16-French Foley catheter with 5 mL balloon was passed through the port site.  The aspiration site in the gallbladder was enlarged with a Maryland 5 mL balloon was filled with saline.  The aspiration of the Foley catheter resulted in clear white bile.  This decompressed the gallbladder.  The 5 mm trocar in the anterior axillary line was removed and a #10 flat  Jackson-Pratt drain was passed through the port site and positioned alongside the gallbladder and the right flank.  The patient had some bleeding from her liver edge adjacent to the gallbladder.  This was minor and was controlled with 2 small pieces of Surgicel.  The 12-mm trocar in the subxiphoid midline was then removed and the fascia was closed with a 0 Vicryl suture using a port closure device.  The abdomen was deflated and the Foley catheter was gently pulled close to the skin so that the end of the gallbladder was adjacent to the abdominal wall.  The Foley catheter was then sutured to the skin with 2-0 nylon.  A JP was sutured to the skin with 2-0 nylon.  The Hasson trocar was removed and the fascia was closed with a figure-of-eight 0 Vicryl suture.  The wounds were irrigated, hemostasis was obtained, and the two 12 mm trocar sites were closed with running 4-0 Monocryl suture.  Steri-Strips and sterile dressings were applied to all wounds.  The JP was placed to bulb suction.  The tube cholecystostomy was placed to Foley bag gravity drainage.


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