lcathey@smsc.org
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Would it be appropriate to bill for the enterotomy repair in this case. Was thinking I could use 44602-59 or 51. I've also read in some cased it is not appropriate to bill for the unplanned repair. Thanks for your help!!
PREOPERATIVE DIAGNOSIS:
Gallstones.
POSTOPERATIVE DIAGNOSIS:
Gallstones.
PROCEDURE PERFORMED:
1. Open cholecystectomy with intraoperative cholangiogram.
2. Repair of enterotomy.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
Minimal.
SPECIMEN:
Gallbladder.
FINDINGS:
Laparoscopically, the patient had a very thickened gallbladder.
The transverse colon and the presumed duodenum were adherent to
the neck of the gallbladder. I was able to dissect these off,
but it appeared she had a small pinhole in her duodenum. Further
investigation in the open procedure showed this to be more in the
region of the pylorus. Her cholangiogram was unremarkable with a
long cystic duct.
OPERATIVE REPORT:
Upon induction of adequate anesthesia, the patient's abdomen was
prepped and draped in the usual sterile manner. A curvilinear
supraumbilical incision was performed and in the open fashion, a
Hasson trocar was introduced. After an adequate CO2
pneumoperitoneum was achieved, I placed 2 operating trocars in
the right upper quadrant under direct visualization. A scan of
the abdomen revealed the above findings. With some delicate
dissection, I was able to get the colon off of the gallbladder
without any apparent injury and I dissected down and found what
appeared to be probably the cystic artery or cystic duct and deep
to that another structure which could have been a cystic duct and
what appeared to be the duodenum closely adherent to this lower
structure. Dissection of this specimen off of this surrounding
area was difficult and in fact in doing delicate dissection, I
noticed a splash of bile and at that point, with the anatomy not
extremely clear, I elected to open her. We took out the
laparoscopic instruments and I closed the fascia at the umbilicus
with interrupted 0 Vicryl sutures. I connected the 2
laparoscopic trocar sites to make 1 subcostal Kocher incision. I
used cautery to go down through the musculature and enter the
abdomen.
At this point, I started taking the gallbladder down retrograde
from the liver with cautery and this was easily accomplished as
the gallbladder was not large but was significantly thickened
from chronic inflammation. I had previously laparoscopically
found that the anterior structure was the cystic artery and then
doubly clipped and divided this. The cystic duct was obvious but
had this adherent bowel present. I could see a small hole in the
tubular structure and could not tell whether this was going into
the bowel or into the cystic duct. Efforts at trying to get a
cholangiogram through that area were unremarkable and showed just
extravasation so I went ahead and made an opening in the cystic
duct, and could not get a satisfactory cholangiogram as
everything came out that other small hole. With the open
procedure, I was able to get the gallbladder down and took the
gallbladder out and still could not get a catheter to thread into
this small area.
I dissected the bowel off of the cystic duct and it turned out
that this was pylorus duodenal junction at and the small hole was
in the pylorus. I went ahead and closed it in 2 layers with
running 3-0 Monocryl suture, followed by Lemberted 3-0 silk
sutures with a very adequate closure. This allowed me the focus
my attention more on the cystic duct stump. Multiple attempts
were made at trying to cannulate this area and I was unsuccessful
until I trimmed off some of the adventitial tissue around it and
was able to get a cholangiogram and found that the cystic duct
actually was quite long and allowed me to doubly clipped and
divided. The patient was allowed me to doubly clip it. With
this clipped and the artery clipped, I continued to dissect the
gallbladder out, came across another small bleeding vessel and
clipped it as well.
With the gallbladder removed, the enterotomy repaired and the
area thoroughly irrigated and no evidence of bleeding or bile
leakage from any structure. I placed a JP Blake drain through a
separate stab incision into the area where the enterotomy had
been. I secured the drain at the skin level with a silk suture
and closed the posterior fascia level with a running #1 Vicryl
Plus suture and the next fascia level with interrupted #1 Vicryl
Plus sutures and then infiltrated the wound with Marcaine and
then closed the subcutaneous tissue with interrupted 3-0 Monocryl
suture and the skin at both sites with running 4-0 subcuticular
Monocryl suture, followed by Dermabond.
PREOPERATIVE DIAGNOSIS:
Gallstones.
POSTOPERATIVE DIAGNOSIS:
Gallstones.
PROCEDURE PERFORMED:
1. Open cholecystectomy with intraoperative cholangiogram.
2. Repair of enterotomy.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
Minimal.
SPECIMEN:
Gallbladder.
FINDINGS:
Laparoscopically, the patient had a very thickened gallbladder.
The transverse colon and the presumed duodenum were adherent to
the neck of the gallbladder. I was able to dissect these off,
but it appeared she had a small pinhole in her duodenum. Further
investigation in the open procedure showed this to be more in the
region of the pylorus. Her cholangiogram was unremarkable with a
long cystic duct.
OPERATIVE REPORT:
Upon induction of adequate anesthesia, the patient's abdomen was
prepped and draped in the usual sterile manner. A curvilinear
supraumbilical incision was performed and in the open fashion, a
Hasson trocar was introduced. After an adequate CO2
pneumoperitoneum was achieved, I placed 2 operating trocars in
the right upper quadrant under direct visualization. A scan of
the abdomen revealed the above findings. With some delicate
dissection, I was able to get the colon off of the gallbladder
without any apparent injury and I dissected down and found what
appeared to be probably the cystic artery or cystic duct and deep
to that another structure which could have been a cystic duct and
what appeared to be the duodenum closely adherent to this lower
structure. Dissection of this specimen off of this surrounding
area was difficult and in fact in doing delicate dissection, I
noticed a splash of bile and at that point, with the anatomy not
extremely clear, I elected to open her. We took out the
laparoscopic instruments and I closed the fascia at the umbilicus
with interrupted 0 Vicryl sutures. I connected the 2
laparoscopic trocar sites to make 1 subcostal Kocher incision. I
used cautery to go down through the musculature and enter the
abdomen.
At this point, I started taking the gallbladder down retrograde
from the liver with cautery and this was easily accomplished as
the gallbladder was not large but was significantly thickened
from chronic inflammation. I had previously laparoscopically
found that the anterior structure was the cystic artery and then
doubly clipped and divided this. The cystic duct was obvious but
had this adherent bowel present. I could see a small hole in the
tubular structure and could not tell whether this was going into
the bowel or into the cystic duct. Efforts at trying to get a
cholangiogram through that area were unremarkable and showed just
extravasation so I went ahead and made an opening in the cystic
duct, and could not get a satisfactory cholangiogram as
everything came out that other small hole. With the open
procedure, I was able to get the gallbladder down and took the
gallbladder out and still could not get a catheter to thread into
this small area.
I dissected the bowel off of the cystic duct and it turned out
that this was pylorus duodenal junction at and the small hole was
in the pylorus. I went ahead and closed it in 2 layers with
running 3-0 Monocryl suture, followed by Lemberted 3-0 silk
sutures with a very adequate closure. This allowed me the focus
my attention more on the cystic duct stump. Multiple attempts
were made at trying to cannulate this area and I was unsuccessful
until I trimmed off some of the adventitial tissue around it and
was able to get a cholangiogram and found that the cystic duct
actually was quite long and allowed me to doubly clipped and
divided. The patient was allowed me to doubly clip it. With
this clipped and the artery clipped, I continued to dissect the
gallbladder out, came across another small bleeding vessel and
clipped it as well.
With the gallbladder removed, the enterotomy repaired and the
area thoroughly irrigated and no evidence of bleeding or bile
leakage from any structure. I placed a JP Blake drain through a
separate stab incision into the area where the enterotomy had
been. I secured the drain at the skin level with a silk suture
and closed the posterior fascia level with a running #1 Vicryl
Plus suture and the next fascia level with interrupted #1 Vicryl
Plus sutures and then infiltrated the wound with Marcaine and
then closed the subcutaneous tissue with interrupted 3-0 Monocryl
suture and the skin at both sites with running 4-0 subcuticular
Monocryl suture, followed by Dermabond.