I'm thinking 47600... Would you agree?? Thank you
A curvilinear supraumbilical incision was then made and carried through the subcutaneous tissues down to the fascia at the base of the umbilicus. The umbilical stock was grasped and elevated and a fascial incision was then made. Heavy Vicryl was placed on either side of the fascial defect. A Hasson trocar was then entered in the abdomen and pneumoperitoneum was established. Initial evaluation with the laparoscope noted no evidence of injury to the bowel secondary to port placement. Of note, in the right upper quadrant, there was a large inflammatory mass with distortion of the placement of the liver. A subcostal 5-mm port was then placed through a separate stab incision under direct vision. A bowel grasper was then used to bluntly dissect the colon and omentum from this inflammatory mass and detach the inflamed gallbladder from the anterior abdominal wall. Of note, there were multiple areas of spotty blackened regions concerning for a gangrenous gallbladder. Once the gallbladder was delivered from its adhesions, appropriate placement was then able to be determined and a subxiphoid port was then placed through a separate stab incision. A separate 5-mm subcostal port was then placed under direct vision. The gallbladder was then decompressed using a large needle delivered through the 5-mm port. There was thick black bile noted to be returned. The gallbladder was then grasped and elevated. The duodenum and stomach were gently swept away from the adherents to the inflamed gallbladder. The peritoneum over the neck of the gallbladder was then incised and divided. The gallbladder was then able to be grasped and the peritoneum and surrounding tissue the neck of the gallbladder as it met with the cystic duct, was able to be gently dissected. There was a significant amount of inflammatory reaction that was in the early beginnings of fibrosis in this region. The cystic artery and cystic duct were then able to be identified. They were circumferentially dissected and each was doubly clipped proximally and a single clip was placed distally and then they were subsequently divided. The gallbladder was then dissected from the liver bed using electrocautery. Of note, there is significant amount of oozing from the gallbladder bed and looking down to the base of the gallbladder fossa there was a large amount of clot. A hemostatic measures were taken using suction clipping of the hepatic parenchyma. The bleeding from the superior aspect of the parenchyma slowed significantly, however, clot still continued to accumulate. There was no visible areas of bleeding noted. The clot was evacuated and there was still ongoing bleeding that was from an unidentifiable source. The gallbladder was then dissected from the remainder of the gallbladder bed and placed in an EndoCatch bag. Other hemostatic measures were taken with electrocautery and suction evacuation of the clot. However, the bleeding was not able to be stopped appropriately. Decision was made at this time due to the complete lack of visualization to convert to an open procedure. The subxiphoid port was removed and an incision was then made connecting the 2 ports to the subxiphoid and subcostal port. This incision was carried through the subcutaneous tissue as well as the fascia and the abdomen was then entered. Significant amount of clot was then evacuated from the gallbladder fossa which was then packed with a lap sponge. The Bookwalter was placed and the bowels were maneuvered out of position. An Argon laser was then used to cauterize the gallbladder fossa in a top-down fashion and the entire inflamed gallbladder, hepatic parenchyma, which was attached to the gallbladder, was exposed and coated. However, there still continued to be a significant amount bleeding. Looking at the cystic artery, the clips appeared to be in place, however, there was a pulsation immediately lateral to the cystic artery that was out of the hernia to the clips. This was then suture ligated using a 4-0 silk suture and hemostasis was then obtained at this point. There was no evidence of further arterial bleeding. There was a significant amount of oozing still from the raw hepatic parenchyma which stopped after being packed with Surgicel. The abdomen was then copiously irrigated with sterile normal saline and the gallbladder was passed off the field as specimen. The previously placed heavy Vicryl sutures were then tied at the umbilical port. A 10 flat JP was then entered through the lateral most subcostal port site and then secured in place using a 3-0 nylon suture. It was then placed to bulb suction. The peritoneum was then closed using running 2-0 Vicryl. The anterior and posterior fascia were then closed in separate layers using running looped PDS. The remaining skin incisions were then closed using staples. Dressings were then applied.
A curvilinear supraumbilical incision was then made and carried through the subcutaneous tissues down to the fascia at the base of the umbilicus. The umbilical stock was grasped and elevated and a fascial incision was then made. Heavy Vicryl was placed on either side of the fascial defect. A Hasson trocar was then entered in the abdomen and pneumoperitoneum was established. Initial evaluation with the laparoscope noted no evidence of injury to the bowel secondary to port placement. Of note, in the right upper quadrant, there was a large inflammatory mass with distortion of the placement of the liver. A subcostal 5-mm port was then placed through a separate stab incision under direct vision. A bowel grasper was then used to bluntly dissect the colon and omentum from this inflammatory mass and detach the inflamed gallbladder from the anterior abdominal wall. Of note, there were multiple areas of spotty blackened regions concerning for a gangrenous gallbladder. Once the gallbladder was delivered from its adhesions, appropriate placement was then able to be determined and a subxiphoid port was then placed through a separate stab incision. A separate 5-mm subcostal port was then placed under direct vision. The gallbladder was then decompressed using a large needle delivered through the 5-mm port. There was thick black bile noted to be returned. The gallbladder was then grasped and elevated. The duodenum and stomach were gently swept away from the adherents to the inflamed gallbladder. The peritoneum over the neck of the gallbladder was then incised and divided. The gallbladder was then able to be grasped and the peritoneum and surrounding tissue the neck of the gallbladder as it met with the cystic duct, was able to be gently dissected. There was a significant amount of inflammatory reaction that was in the early beginnings of fibrosis in this region. The cystic artery and cystic duct were then able to be identified. They were circumferentially dissected and each was doubly clipped proximally and a single clip was placed distally and then they were subsequently divided. The gallbladder was then dissected from the liver bed using electrocautery. Of note, there is significant amount of oozing from the gallbladder bed and looking down to the base of the gallbladder fossa there was a large amount of clot. A hemostatic measures were taken using suction clipping of the hepatic parenchyma. The bleeding from the superior aspect of the parenchyma slowed significantly, however, clot still continued to accumulate. There was no visible areas of bleeding noted. The clot was evacuated and there was still ongoing bleeding that was from an unidentifiable source. The gallbladder was then dissected from the remainder of the gallbladder bed and placed in an EndoCatch bag. Other hemostatic measures were taken with electrocautery and suction evacuation of the clot. However, the bleeding was not able to be stopped appropriately. Decision was made at this time due to the complete lack of visualization to convert to an open procedure. The subxiphoid port was removed and an incision was then made connecting the 2 ports to the subxiphoid and subcostal port. This incision was carried through the subcutaneous tissue as well as the fascia and the abdomen was then entered. Significant amount of clot was then evacuated from the gallbladder fossa which was then packed with a lap sponge. The Bookwalter was placed and the bowels were maneuvered out of position. An Argon laser was then used to cauterize the gallbladder fossa in a top-down fashion and the entire inflamed gallbladder, hepatic parenchyma, which was attached to the gallbladder, was exposed and coated. However, there still continued to be a significant amount bleeding. Looking at the cystic artery, the clips appeared to be in place, however, there was a pulsation immediately lateral to the cystic artery that was out of the hernia to the clips. This was then suture ligated using a 4-0 silk suture and hemostasis was then obtained at this point. There was no evidence of further arterial bleeding. There was a significant amount of oozing still from the raw hepatic parenchyma which stopped after being packed with Surgicel. The abdomen was then copiously irrigated with sterile normal saline and the gallbladder was passed off the field as specimen. The previously placed heavy Vicryl sutures were then tied at the umbilical port. A 10 flat JP was then entered through the lateral most subcostal port site and then secured in place using a 3-0 nylon suture. It was then placed to bulb suction. The peritoneum was then closed using running 2-0 Vicryl. The anterior and posterior fascia were then closed in separate layers using running looped PDS. The remaining skin incisions were then closed using staples. Dressings were then applied.