Shay0287
New
I need help. Is this 47563 or 47564 with a Modifier? Is the stone removal and balloon sphinecteroplasty inclusive?
FINDINGS: Single stone in common bile duct seen on initial cholangiogram. Stone had passed after repeated catheterization of bile ducts.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. Bilateral lower extremity sequential compressive devices were placed and general endotracheal anesthesia was established by the anesthesia team. The patient's stomach was decompressed with an orogastric tube. The patient's anterior abdomen was sterilely prepared and draped in the sterile surgical fashion. A 5-mm incision was made in the right upper quadrant in the anterior axillary line just inferior to the costal margin. Through this incision, a Veress needle was introduced. The aspiration and drop tests were appropriate. The abdomen was insufflated with carbon dioxide gas to a pressure of 15 mmHg. The initial pressures were low and flows were high. Once the abdomen had been fully insufflated to a pressure of 15 mmHg, the Veress needle was removed and a 5-mm blunt trocar was inserted through the same incision. A 5-mm, 30-degree angled telescope was introduced through this trocar, and the abdominal contents were surveyed. There was no evidence of any visceral injury from placement of the Veress needle or 5-mm trocar.
Additional ports were then placed under direct laparoscopic visualization. Prior to each incision, the area was infiltrated with local anesthetic. A 11-mm port was placed at the umbilicus, a 5-mm port was placed in the mid epigastrium and a 5-mm port was placed in the mid right upper quadrant. The patient was placed in the reverse Trendelenburg position and rotated towards the left. The fundus of the gallbladder was grasped and retracted anteriorly superiorly. There were noted to be omental adhesions to the gallbladder and they were divided with the hook electrocautery. The infundibulum of the gallbladder was retracted laterally. The peritoneum overlying the infundibulum of the gallbladder was stripped down. That revealed the cystic duct. The cystic duct was bluntly dissected from the surrounding tissues in a circumferential fashion and it was visualized as running directly into the gallbladder. Additional blunt dissection of the triangle of Calot revealed the cystic artery. The cystic artery was then bluntly dissected from the surrounding tissues in a circumferential fashion and it was visualized as running directly onto the gallbladder. The critical view was obtained. The cystic artery was clipped twice distally and twice proximally and transected in-between. Additionally, a posterior branch of the cystic artery was clipped twice distally and twice proximally and transected in-between. The cystic duct was clipped once at its junction with the gallbladder.
A small incision was made on the cystic duct and into that, a Mixter cholangiocatheter was inserted into the cystic duct and a cholangiogram was performed utilizing real-time fluoroscopy. The cholangiogram was abnormal with evidence of a filling defect in the common bile duct. Glucagon was administered and the catheter was repeatedly flushed. Another cholangiogram was performed and it remained abnormal.
An additional 5-mm port was placed in the right upper quadrant to facilitate common bile duct exploration. A ureteroscope was set up as a choledochoscope. Multiple attempts were made to place it into the cystic duct and down into the distal common bile duct, but the cystic duct was too small. The cholangiogram catheter was again placed into the cystic duct and a guide wire was passed through the cholangiocatheter. Passing the ureteroscope over the guidewire was also not successful in getting the scope to pass into the cystic duct.
A 4cm long balloon dilator was passed over the guidewire. It was positioned across the sphincter of Oddi and inflated for 5 minutes. The catheter was repeatedly flushed as it was slowly withdrawn under fluoroscopic guidance, so as to flush out to common bile duct.
The Mixter cholangiocatheter was again inserted into the cystic duct and a cholangiogram was performed utilizing real-time fluoroscopy. The cholangiogram was normal. There was good flow of contrast into the duodenum. There was no evidence of any filling defect in the common bile duct. There was no evidence of any iatrogenic bile duct injury. There was confirmation of the placement of the cholangiocatheter within the cystic duct. The cholangiocatheter was then removed.
The cystic duct was clipped three times distally and three times proximally and transected in-between. An endoloop was also placed on the cystic duct stump. The gallbladder was dissected off of the liver bed using hook electrocautery. The individual bleeding points were controlled with the electrocautery. The gallbladder was fully dissected off of the liver bed and then placed in an EndoCatch bag and removed from the abdomen and sent to pathology as a specimen.
The right upper quadrant and liver bed were then thoroughly irrigated. The irrigant was suctioned out of the abdomen. The liver bed was carefully inspected and there was no evidence of any bleeding or bile leak. The clips were visualized as being intact on the cystic artery and cystic duct. There was no evidence of any bleeding or bile leak from the cystic artery or cystic duct. The ports were then removed sequentially under direct visualization and they were noted to be hemostatic. The abdomen was de-sufflated. The fascia at the 11-mm port site was closed with a #0 Vicryl suture. The skin at each incision was closed with #4-0 Monocryl subcuticular sutures. The wounds were dressed with Dermabond.
The patient was awakened from general endotracheal anesthesia and was safely extubated. The patient was taken to the recovery room in stable condition having tolerated the procedure well.
FINDINGS: Single stone in common bile duct seen on initial cholangiogram. Stone had passed after repeated catheterization of bile ducts.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. Bilateral lower extremity sequential compressive devices were placed and general endotracheal anesthesia was established by the anesthesia team. The patient's stomach was decompressed with an orogastric tube. The patient's anterior abdomen was sterilely prepared and draped in the sterile surgical fashion. A 5-mm incision was made in the right upper quadrant in the anterior axillary line just inferior to the costal margin. Through this incision, a Veress needle was introduced. The aspiration and drop tests were appropriate. The abdomen was insufflated with carbon dioxide gas to a pressure of 15 mmHg. The initial pressures were low and flows were high. Once the abdomen had been fully insufflated to a pressure of 15 mmHg, the Veress needle was removed and a 5-mm blunt trocar was inserted through the same incision. A 5-mm, 30-degree angled telescope was introduced through this trocar, and the abdominal contents were surveyed. There was no evidence of any visceral injury from placement of the Veress needle or 5-mm trocar.
Additional ports were then placed under direct laparoscopic visualization. Prior to each incision, the area was infiltrated with local anesthetic. A 11-mm port was placed at the umbilicus, a 5-mm port was placed in the mid epigastrium and a 5-mm port was placed in the mid right upper quadrant. The patient was placed in the reverse Trendelenburg position and rotated towards the left. The fundus of the gallbladder was grasped and retracted anteriorly superiorly. There were noted to be omental adhesions to the gallbladder and they were divided with the hook electrocautery. The infundibulum of the gallbladder was retracted laterally. The peritoneum overlying the infundibulum of the gallbladder was stripped down. That revealed the cystic duct. The cystic duct was bluntly dissected from the surrounding tissues in a circumferential fashion and it was visualized as running directly into the gallbladder. Additional blunt dissection of the triangle of Calot revealed the cystic artery. The cystic artery was then bluntly dissected from the surrounding tissues in a circumferential fashion and it was visualized as running directly onto the gallbladder. The critical view was obtained. The cystic artery was clipped twice distally and twice proximally and transected in-between. Additionally, a posterior branch of the cystic artery was clipped twice distally and twice proximally and transected in-between. The cystic duct was clipped once at its junction with the gallbladder.
A small incision was made on the cystic duct and into that, a Mixter cholangiocatheter was inserted into the cystic duct and a cholangiogram was performed utilizing real-time fluoroscopy. The cholangiogram was abnormal with evidence of a filling defect in the common bile duct. Glucagon was administered and the catheter was repeatedly flushed. Another cholangiogram was performed and it remained abnormal.
An additional 5-mm port was placed in the right upper quadrant to facilitate common bile duct exploration. A ureteroscope was set up as a choledochoscope. Multiple attempts were made to place it into the cystic duct and down into the distal common bile duct, but the cystic duct was too small. The cholangiogram catheter was again placed into the cystic duct and a guide wire was passed through the cholangiocatheter. Passing the ureteroscope over the guidewire was also not successful in getting the scope to pass into the cystic duct.
A 4cm long balloon dilator was passed over the guidewire. It was positioned across the sphincter of Oddi and inflated for 5 minutes. The catheter was repeatedly flushed as it was slowly withdrawn under fluoroscopic guidance, so as to flush out to common bile duct.
The Mixter cholangiocatheter was again inserted into the cystic duct and a cholangiogram was performed utilizing real-time fluoroscopy. The cholangiogram was normal. There was good flow of contrast into the duodenum. There was no evidence of any filling defect in the common bile duct. There was no evidence of any iatrogenic bile duct injury. There was confirmation of the placement of the cholangiocatheter within the cystic duct. The cholangiocatheter was then removed.
The cystic duct was clipped three times distally and three times proximally and transected in-between. An endoloop was also placed on the cystic duct stump. The gallbladder was dissected off of the liver bed using hook electrocautery. The individual bleeding points were controlled with the electrocautery. The gallbladder was fully dissected off of the liver bed and then placed in an EndoCatch bag and removed from the abdomen and sent to pathology as a specimen.
The right upper quadrant and liver bed were then thoroughly irrigated. The irrigant was suctioned out of the abdomen. The liver bed was carefully inspected and there was no evidence of any bleeding or bile leak. The clips were visualized as being intact on the cystic artery and cystic duct. There was no evidence of any bleeding or bile leak from the cystic artery or cystic duct. The ports were then removed sequentially under direct visualization and they were noted to be hemostatic. The abdomen was de-sufflated. The fascia at the 11-mm port site was closed with a #0 Vicryl suture. The skin at each incision was closed with #4-0 Monocryl subcuticular sutures. The wounds were dressed with Dermabond.
The patient was awakened from general endotracheal anesthesia and was safely extubated. The patient was taken to the recovery room in stable condition having tolerated the procedure well.