jdibble
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I am not sure what codes to use for this laparoscopic procedure! If someone could please review this OP note and help it would be appreciated!! So far I have tentatively used unlisted codes 47379, 44238 and 47562-52 for the cholecystectomy attempt. I am not sure if I am looking at this correctly though and if there are codes for what is being done.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed on the table in supine position. After adequate general anesthesia, he was prepped and draped in a sterile fashion. A Foley catheter was then placed. Incision was made in the previous line of incision previous, periumbilical region and a 5 mm blade with trocars was placed under direct vision through it. Once intraperitoneal, the belly was insufflated with 15 mm of mercury of pressure. Inspection was undertaken. There was noted to be a lot of distended small bowel and the area of the liver was a lot of omentum and the liver was not well visualized to the omentum. Then another incision was made in the right upper lateral quadrant and a 5 mm blade with trocars was placed under direct vision through it. The Babcock was used to attempt to mobilize the small bowel and identify the transition point with such difficulty with distended bowel attempt. This was aborted and it was attempted to look up at the liver and retract the omentum down to see the gallbladder. There was noted to be a lot of inflammation in this area as well. At this point, the trocar was removed out of the midline and the trocar on the side right upper quadrant, CO2 was placed through it. The insufflation and then the incision was made from the hand port. The small wound protector was placed and the hand port was placed. The laparoscope was placed into the belly and then the hand was introduced. It was used easily found the area of the small bowel with the stone in it. This was pulled up to the wound and a longitudinal incision was created and the stone was extracted. Then a transverse repair, 2 layers with 3-0 Vicryl running stitch and 3-0 silk Lembert stitches was created. This was placed back in the belly. Attention was then directed up to the liver. The patient was repositioned and another trocar was placed in the epigastrium. The trocar was placed in an attempt to get around the falciform ligament. When it was not able to be visualized around it, then another incision was made to the left of the hand port in the upper abdomen. A 5 mm blade was placed under direct vision through it. Using the laparoscope hand port and retractor, attempts were made to dissect down to take down the gallbladder in the dome down position. After it was not able to be lifted up, the harmonic scalpel was used to dissect.
Between placing the trocar next to the hand port and then starting dissection of the gallbladder, so dissection was undertaken an initially was attempted to lift up the liver when it could be lifted up. Dissection along the upper portion of the omentum attached to the liver was undertaken with the harmonic scalpel. Slow, tedious dissection was undertaken and then it was taken down on the lateral aspect. Attempts were made several times to lift up the liver and better visualize the gallbladder. The gallbladder was attempted to be retracted up with the aggressive grasper and continued to take down the adhesions on the anterior border. Again, they were not able to be taken down. So, careful dissection continued to be taken along the liver bed to take down the gallbladder. Finally, when this was not easily accomplished, the small incision in the right upper quadrant was created to try to lift up the gallbladder, continue to dissect it off of the liver bed. Once this was done, then attempts to take the gallbladder was grasped with the Kelly clamp. It was lifted up and again, attempted to be dissected down. It was noted to be very deep and the liver was high up under his ribs, so the incision had to be widened and the Bookwalter_ was used to retract the surrounding structures. Dissection continued to be taken along the posterior wall of the gallbladder and then on the side, a little bit of dissection was able to be done. Then medially, minimal dissection was done due to the dense adhesions and for fear of getting into the common bile duct or hepatic artery or other structures. However, while dissecting on the posterior aspect of the gallbladder down to the liver bed, some bleeding occurred and attempts were used to control and initiate with venous. A right angle clamp was used to grasp it and a stick tie was used to control the oozing. As this was being controlled, it seemed like more and more bleeding from the liver bed was encountered, so several attempts were made to control the bleeding with a stitch. No chromic or tapering liver stitches were obtained. One tie along the liver bed was achieved. Then the bleeding was coming from further down along the posterior aspect of the gallbladder so another right angle clamp was placed. Pressure was held. It appeared then at this point arterial bleeding.
At this point, when it was difficult to get a handle on the bleeding due to the size of the liver and the gallbladder being retracted and the surrounding structures being inflamed, Dr. _____ was called to assist. Pressure was held. The Doppler was used to identify surrounding vasculature when it was noted thatthere was still a strong signal to the liver and porta hepatis and the liver itself. Another right angle clamp was placed to control the bleeding. When this was placed, the 3-0 Prolene stitch was used to do a figure-of-eight stick tie to control bleeding on 2 separate vessels. One stitch was used to control bleeding, pressure was held. Then attention was directed to the gallbladder and cholecystoduodenostomy.
The duodenotomy was closed in 2 layers with a 3-0 Vicryl stitch through and through. Then the contracted gallbladder was used for a bolster over it. The FloSeal was in place along the liver bed for more assurance of controlling the oozing. A 19 Blake drain was then placed through a separate stab through one of the separate trocar sites. It was secured in place with a 2-0 nylon stitch. It was placed in the hepatic space. Then the fascia was closed in this right upper quadrant incision in 3 layers with #1 looped PDS in the posterior fascia and anterior fascia and then 3-0 Vicryl in the superficial fascia interrupted. Staples were used for the skin and 0.5% Marcaine was injected around this area prior to closing. Then the 10-11 mm trocar site was closed in 2 layers with the 0 Vicryl stitch in the fascia and 4-0 Monocryl subcuticular stitch in the skin. The 6 mm trocar site was closed with a 4-0 Monocryl subcuticular stitch. Then attention was directed to the periumbilical hand port site. The fascia was approximated with running #1 PDS above and below, unlooped and tied. Then subcutaneous was irrigated with saline. The skin was approximated with staples. Bacitracin, Telfa and Tegaderm were placed on the laparoscopic site. Then OpSite was used for the right upper quadrant incision and the line incision and the tied around the drain. The patient was left intubated and taken to the recovery room in fair condition. Planning to give another unit of blood in recovery. He was left on the ventilator and taken to intensive care unit.
Thank you for all the help I can get!
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, placed on the table in supine position. After adequate general anesthesia, he was prepped and draped in a sterile fashion. A Foley catheter was then placed. Incision was made in the previous line of incision previous, periumbilical region and a 5 mm blade with trocars was placed under direct vision through it. Once intraperitoneal, the belly was insufflated with 15 mm of mercury of pressure. Inspection was undertaken. There was noted to be a lot of distended small bowel and the area of the liver was a lot of omentum and the liver was not well visualized to the omentum. Then another incision was made in the right upper lateral quadrant and a 5 mm blade with trocars was placed under direct vision through it. The Babcock was used to attempt to mobilize the small bowel and identify the transition point with such difficulty with distended bowel attempt. This was aborted and it was attempted to look up at the liver and retract the omentum down to see the gallbladder. There was noted to be a lot of inflammation in this area as well. At this point, the trocar was removed out of the midline and the trocar on the side right upper quadrant, CO2 was placed through it. The insufflation and then the incision was made from the hand port. The small wound protector was placed and the hand port was placed. The laparoscope was placed into the belly and then the hand was introduced. It was used easily found the area of the small bowel with the stone in it. This was pulled up to the wound and a longitudinal incision was created and the stone was extracted. Then a transverse repair, 2 layers with 3-0 Vicryl running stitch and 3-0 silk Lembert stitches was created. This was placed back in the belly. Attention was then directed up to the liver. The patient was repositioned and another trocar was placed in the epigastrium. The trocar was placed in an attempt to get around the falciform ligament. When it was not able to be visualized around it, then another incision was made to the left of the hand port in the upper abdomen. A 5 mm blade was placed under direct vision through it. Using the laparoscope hand port and retractor, attempts were made to dissect down to take down the gallbladder in the dome down position. After it was not able to be lifted up, the harmonic scalpel was used to dissect.
Between placing the trocar next to the hand port and then starting dissection of the gallbladder, so dissection was undertaken an initially was attempted to lift up the liver when it could be lifted up. Dissection along the upper portion of the omentum attached to the liver was undertaken with the harmonic scalpel. Slow, tedious dissection was undertaken and then it was taken down on the lateral aspect. Attempts were made several times to lift up the liver and better visualize the gallbladder. The gallbladder was attempted to be retracted up with the aggressive grasper and continued to take down the adhesions on the anterior border. Again, they were not able to be taken down. So, careful dissection continued to be taken along the liver bed to take down the gallbladder. Finally, when this was not easily accomplished, the small incision in the right upper quadrant was created to try to lift up the gallbladder, continue to dissect it off of the liver bed. Once this was done, then attempts to take the gallbladder was grasped with the Kelly clamp. It was lifted up and again, attempted to be dissected down. It was noted to be very deep and the liver was high up under his ribs, so the incision had to be widened and the Bookwalter_ was used to retract the surrounding structures. Dissection continued to be taken along the posterior wall of the gallbladder and then on the side, a little bit of dissection was able to be done. Then medially, minimal dissection was done due to the dense adhesions and for fear of getting into the common bile duct or hepatic artery or other structures. However, while dissecting on the posterior aspect of the gallbladder down to the liver bed, some bleeding occurred and attempts were used to control and initiate with venous. A right angle clamp was used to grasp it and a stick tie was used to control the oozing. As this was being controlled, it seemed like more and more bleeding from the liver bed was encountered, so several attempts were made to control the bleeding with a stitch. No chromic or tapering liver stitches were obtained. One tie along the liver bed was achieved. Then the bleeding was coming from further down along the posterior aspect of the gallbladder so another right angle clamp was placed. Pressure was held. It appeared then at this point arterial bleeding.
At this point, when it was difficult to get a handle on the bleeding due to the size of the liver and the gallbladder being retracted and the surrounding structures being inflamed, Dr. _____ was called to assist. Pressure was held. The Doppler was used to identify surrounding vasculature when it was noted thatthere was still a strong signal to the liver and porta hepatis and the liver itself. Another right angle clamp was placed to control the bleeding. When this was placed, the 3-0 Prolene stitch was used to do a figure-of-eight stick tie to control bleeding on 2 separate vessels. One stitch was used to control bleeding, pressure was held. Then attention was directed to the gallbladder and cholecystoduodenostomy.
The duodenotomy was closed in 2 layers with a 3-0 Vicryl stitch through and through. Then the contracted gallbladder was used for a bolster over it. The FloSeal was in place along the liver bed for more assurance of controlling the oozing. A 19 Blake drain was then placed through a separate stab through one of the separate trocar sites. It was secured in place with a 2-0 nylon stitch. It was placed in the hepatic space. Then the fascia was closed in this right upper quadrant incision in 3 layers with #1 looped PDS in the posterior fascia and anterior fascia and then 3-0 Vicryl in the superficial fascia interrupted. Staples were used for the skin and 0.5% Marcaine was injected around this area prior to closing. Then the 10-11 mm trocar site was closed in 2 layers with the 0 Vicryl stitch in the fascia and 4-0 Monocryl subcuticular stitch in the skin. The 6 mm trocar site was closed with a 4-0 Monocryl subcuticular stitch. Then attention was directed to the periumbilical hand port site. The fascia was approximated with running #1 PDS above and below, unlooped and tied. Then subcutaneous was irrigated with saline. The skin was approximated with staples. Bacitracin, Telfa and Tegaderm were placed on the laparoscopic site. Then OpSite was used for the right upper quadrant incision and the line incision and the tied around the drain. The patient was left intubated and taken to the recovery room in fair condition. Planning to give another unit of blood in recovery. He was left on the ventilator and taken to intensive care unit.
Thank you for all the help I can get!
