ksb0211
Guest
What started out as a simple lap chole turned into a headache of a case. I'm hoping that someone else can give me some ideas on coding this one out because I really want to make sure that I'm not missing anything. Thanks.
PROCEDURE
The patient was brought to the operating room after the attainment of sufficient general anesthesia, he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Made a 5 mm infraumbilical incision and entered the abdominal cavity with a Veress needle. Insufflated to 14 mmHg. Placed another 5 mm port at the xiphoid and another one in the mid clavicular line. Developed our exposure, saw that the omentum was plastered up against the gallbladder and it was really hard to visualize the gallbladder. We took down some surrounding adhesions and dissected free. As we began our dissection we could see that the proximal transverse colon just at the hepatic flexure was just adhesed to the gallbladder at the fundus. We tried to take it down and did some blunt dissection and finally realized that were going to make a problem if we did not switch gears and so what we did is we decided to open, figuring that there was a potential that this would represent a fistulous connection between the gallbladder and the transverse colon. Went in and opened and saw that that was in fact the case. We began to take this down and once we got into it we saw that the gallbladder was the gallbladder was remarkably contracted and the colon was adhesed. It was only adhesed over about a 1 cm area. We took it down and we could see that we were into both the gallbladder and the colon. We went ahead and closed the colonic rent with interrupted sutures of 3-0 Vicryl through a mucosal serosal stitch and then came back with Lembert's of 3-0 silk, put about 4 those in and then covered it with some surrounding omentum, almost like a Graham patch would be done. That really resulted in a nice repair of the colon. We then turned our attention to the gallbladder. We began to dissect down and we found what we thought was the end of the gallbladder. We dissected way down south and we looked at it and said, \"Gee this is a big old structure down south.\" Thought we found the cystic duct down in that area, but elected just to take it down from the fundus. We felt that that would probably be safer. So we came down and the gallbladder was just a big adhesed mass adhered to the gallbladder fossa. We started to take it down and as we began our dissection we could see that were just sort of chiseling this gallbladder, using the Bovie right out of the substance of the liver and this was difficult to do. The gallbladder was just so fibrotic. Eventually made our way down south and as we did so we got into some significant bleeding posteriorly. Put a stitch into it, dissected a little more, got the bleeding again and it was apparent at this point that this was the right hepatic artery. We put just two sets of silk and got total control of the bleeding. Really did not bleed all that much but it was just very brisk, but the holes were small. So, at this point we began to look at this and the more we dissected, we realized that we really had was the common duct and that the gallbladder was about the size of a walnut and it was attached to the kind of like a Mirizzi syndrome, at least up top. We carried out some dissection in that area and got a little bit of bile which was disconcerting but we dissected down and finally defined the cystic duct, but we still were not sure if the gallbladder was coming off the right common hepatic duct or not and so I called for Dr. XXXXX to come in just because the anatomy was not quite clear and the amount of fibrosis and inflammation that was present really made it difficult to discern. We knew where the common duct was, we just was not sure where the gallbladder, whether or not the cystic duct was actually the cystic duct or if the cystic duct was the right common hepatic duct. Dissected that free and eventually we just made a small nick into that cystic duct, shot a cholangiogram and also placed a clip up distally to see what this leak was about up high. Went ahead and shot our cholangiogram which showed almost no leak at all. We put a clip in that area to let us know were it was and we defined that our anatomy was normal, that we had the cystic duct and that we were not coming off the right common hepatic duct. Dissected that free once we had had done that and then through that same cholangiogram catheter we switched to a very dilute solution of methylene blue and we could see that the biliary leak was really just an end of a biliary radicle rather than a major structure at all. We just tied that off with some 5-0 PDS and then patched over it. The size of this leak was probably a millimeter or so. Once that was done, we reinjected with methylene blue. We had no further leakage and we were content though we did need to put a T-tube. We then took down the remainder of the gallbladder, scalloping off the right hepatic artery and then transecting the cystic duct and ligating off with 2-0 silk suture. Irrigated copiously, placed a 10 mm Jackson-Pratt and then closed in 2 layers using #1 PDS, first in the posterior sheath and then the anterior sheath. Irrigated the wound. Skin staples and then secured the drain in place. The patient tolerated the
procedure well. Very interesting operation.
PROCEDURE
The patient was brought to the operating room after the attainment of sufficient general anesthesia, he was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Made a 5 mm infraumbilical incision and entered the abdominal cavity with a Veress needle. Insufflated to 14 mmHg. Placed another 5 mm port at the xiphoid and another one in the mid clavicular line. Developed our exposure, saw that the omentum was plastered up against the gallbladder and it was really hard to visualize the gallbladder. We took down some surrounding adhesions and dissected free. As we began our dissection we could see that the proximal transverse colon just at the hepatic flexure was just adhesed to the gallbladder at the fundus. We tried to take it down and did some blunt dissection and finally realized that were going to make a problem if we did not switch gears and so what we did is we decided to open, figuring that there was a potential that this would represent a fistulous connection between the gallbladder and the transverse colon. Went in and opened and saw that that was in fact the case. We began to take this down and once we got into it we saw that the gallbladder was the gallbladder was remarkably contracted and the colon was adhesed. It was only adhesed over about a 1 cm area. We took it down and we could see that we were into both the gallbladder and the colon. We went ahead and closed the colonic rent with interrupted sutures of 3-0 Vicryl through a mucosal serosal stitch and then came back with Lembert's of 3-0 silk, put about 4 those in and then covered it with some surrounding omentum, almost like a Graham patch would be done. That really resulted in a nice repair of the colon. We then turned our attention to the gallbladder. We began to dissect down and we found what we thought was the end of the gallbladder. We dissected way down south and we looked at it and said, \"Gee this is a big old structure down south.\" Thought we found the cystic duct down in that area, but elected just to take it down from the fundus. We felt that that would probably be safer. So we came down and the gallbladder was just a big adhesed mass adhered to the gallbladder fossa. We started to take it down and as we began our dissection we could see that were just sort of chiseling this gallbladder, using the Bovie right out of the substance of the liver and this was difficult to do. The gallbladder was just so fibrotic. Eventually made our way down south and as we did so we got into some significant bleeding posteriorly. Put a stitch into it, dissected a little more, got the bleeding again and it was apparent at this point that this was the right hepatic artery. We put just two sets of silk and got total control of the bleeding. Really did not bleed all that much but it was just very brisk, but the holes were small. So, at this point we began to look at this and the more we dissected, we realized that we really had was the common duct and that the gallbladder was about the size of a walnut and it was attached to the kind of like a Mirizzi syndrome, at least up top. We carried out some dissection in that area and got a little bit of bile which was disconcerting but we dissected down and finally defined the cystic duct, but we still were not sure if the gallbladder was coming off the right common hepatic duct or not and so I called for Dr. XXXXX to come in just because the anatomy was not quite clear and the amount of fibrosis and inflammation that was present really made it difficult to discern. We knew where the common duct was, we just was not sure where the gallbladder, whether or not the cystic duct was actually the cystic duct or if the cystic duct was the right common hepatic duct. Dissected that free and eventually we just made a small nick into that cystic duct, shot a cholangiogram and also placed a clip up distally to see what this leak was about up high. Went ahead and shot our cholangiogram which showed almost no leak at all. We put a clip in that area to let us know were it was and we defined that our anatomy was normal, that we had the cystic duct and that we were not coming off the right common hepatic duct. Dissected that free once we had had done that and then through that same cholangiogram catheter we switched to a very dilute solution of methylene blue and we could see that the biliary leak was really just an end of a biliary radicle rather than a major structure at all. We just tied that off with some 5-0 PDS and then patched over it. The size of this leak was probably a millimeter or so. Once that was done, we reinjected with methylene blue. We had no further leakage and we were content though we did need to put a T-tube. We then took down the remainder of the gallbladder, scalloping off the right hepatic artery and then transecting the cystic duct and ligating off with 2-0 silk suture. Irrigated copiously, placed a 10 mm Jackson-Pratt and then closed in 2 layers using #1 PDS, first in the posterior sheath and then the anterior sheath. Irrigated the wound. Skin staples and then secured the drain in place. The patient tolerated the
procedure well. Very interesting operation.
