ksb0211
Guest
I'm hoping that others see what I see. How would you code this?
POSTOPERATIVE DIAGNOSIS
Emphysematous gallbladder, abscess, possible duodenum colon fistula.
PROCEDURE/OPERATION
Exploratory laparotomy and drainage of abscess.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room. After induction of general anesthesia, the patient was prepped with DuraPrep and draped steriley. Perioperative antibiotics have been administered.
The initial incision was made in the right upper quadrant. The right subcostal incision was carried down through the subcutaneous tissues. The fascia was incised. The rectus muscle was divided. The posterior sheath was incised and the peritoneal cavity entered. There was immediately noted to be some free fluid. The gallbladder was noted to be necrotic. As the pockets were opened purulent material was identified. There was obvious leakage from the gallbladder. Abscess was noted over the right lobe of the liver and down deep into the subhepatic space. The wound was cultured. The Bookwalter retractor was placed. The obvious infection was aspirated. The gallbladder was then mobilized by taking it down from the dome towards the neck of the gallbladder. Multiple small stones were identified. Cystic artery was found and ligated with 2-0 silk suture. Ultimately we identified the cystic duct. It appeared to be viable. An intraoperative cholangiogram was performed by passing a 4-French ureteral stent. The cholangiogram showed no evidence of stone or obstruction. The cystic duct was then tied with the 2-0 silk. The gallbladder was ultimately detached from the liver bed. Dissection was actually fairly easily worked in that the tissue was so necrotic and had no time to scar. The gallbladder was passed off as specimen. The wound was thoroughly irrigated with antibiotic solution. A 10 mm Jackson-Pratt drain was placed in a separate stab incision. The posterior sheath was then closed with running #1 PDS suture. A double-stranded #1 PDS was used anteriorly. The wound was closed with 2-0 Vicryl to the deep tissue and then clipped to the skin. The patient the patient tolerated the procedure and was taken to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSIS
Emphysematous gallbladder, abscess, possible duodenum colon fistula.
PROCEDURE/OPERATION
Exploratory laparotomy and drainage of abscess.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room. After induction of general anesthesia, the patient was prepped with DuraPrep and draped steriley. Perioperative antibiotics have been administered.
The initial incision was made in the right upper quadrant. The right subcostal incision was carried down through the subcutaneous tissues. The fascia was incised. The rectus muscle was divided. The posterior sheath was incised and the peritoneal cavity entered. There was immediately noted to be some free fluid. The gallbladder was noted to be necrotic. As the pockets were opened purulent material was identified. There was obvious leakage from the gallbladder. Abscess was noted over the right lobe of the liver and down deep into the subhepatic space. The wound was cultured. The Bookwalter retractor was placed. The obvious infection was aspirated. The gallbladder was then mobilized by taking it down from the dome towards the neck of the gallbladder. Multiple small stones were identified. Cystic artery was found and ligated with 2-0 silk suture. Ultimately we identified the cystic duct. It appeared to be viable. An intraoperative cholangiogram was performed by passing a 4-French ureteral stent. The cholangiogram showed no evidence of stone or obstruction. The cystic duct was then tied with the 2-0 silk. The gallbladder was ultimately detached from the liver bed. Dissection was actually fairly easily worked in that the tissue was so necrotic and had no time to scar. The gallbladder was passed off as specimen. The wound was thoroughly irrigated with antibiotic solution. A 10 mm Jackson-Pratt drain was placed in a separate stab incision. The posterior sheath was then closed with running #1 PDS suture. A double-stranded #1 PDS was used anteriorly. The wound was closed with 2-0 Vicryl to the deep tissue and then clipped to the skin. The patient the patient tolerated the procedure and was taken to the recovery room in stable condition.
