Operative report Appendectomy
Operative report 1
Preoperative Diagnosis
Acute uncomplicated appendicitis.
Postoperative Diagnosis
Acute suppurative appendicitis without perforation.
Procedure Performed
Laparoscopic appendectomy.
Indication
The patient presented with a 24-hour history of progressively worsening right lower quadrant abdominal pain associated with nausea and leukocytosis. Computed tomography of the abdomen and pelvis demonstrated findings consistent with acute uncomplicated appendicitis. After discussion of the risks, benefits, and alternatives, informed consent was obtained for laparoscopic appendectomy.
Description of the Procedure
The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Intravenous prophylactic antibiotics were administered, and sequential compression devices were applied. The abdomen was prepped and draped in the standard sterile fashion. A formal surgical time-out was performed.
A curvilinear infraumbilical incision was made, and pneumoperitoneum was established using a Veress needle. Carbon dioxide insufflation was maintained at an intra-abdominal pressure of 15 mmHg. A 12-mm umbilical trocar was inserted, and diagnostic laparoscopy confirmed safe abdominal entry. Under direct visualization, a 5-mm suprapubic trocar and a 5-mm left lower quadrant trocar were placed.
Initial exploration demonstrated an acutely inflamed, thickened appendix without evidence of perforation, gangrene, abscess, or diffuse peritonitis. The terminal ileum, cecum, and surrounding bowel were inspected and appeared intact.
The patient was placed in Trendelenburg position with slight left lateral tilt. The appendix was grasped at its tip and elevated anteriorly, placing the mesoappendix under tension. The mesoappendix was divided using a bipolar vessel-sealing device with meticulous control of the appendiceal artery until the base of the appendix was fully exposed.
The appendiceal base was circumferentially dissected free from the cecum. A laparoscopic endoscopic linear stapler was introduced through the umbilical trocar, positioned flush across the base of the appendix at its junction with the cecum, and fired, simultaneously dividing and securely closing the appendiceal stump. The staple line was carefully inspected and found to be intact without bleeding or evidence of leakage.
The appendix was placed into an endoscopic specimen retrieval bag and removed through the umbilical trocar site without contamination of the abdominal wall. The right lower quadrant and pelvis were irrigated with warm normal saline and suctioned until clear. The appendiceal stump and mesoappendix were reinspected and demonstrated excellent hemostasis without bleeding or enteric leakage.
A final laparoscopic survey of the abdominal cavity revealed no additional pathology. Pneumoperitoneum was evacuated under direct visualization, and all trocars were removed. The umbilical fascial defect was closed with interrupted 0-Vicryl sutures. Skin incisions were irrigated and closed with running subcuticular 4-0 Monocryl sutures followed by skin adhesive. Sterile dressings were applied.
Instrument, sponge, and needle counts were correct at the completion of the procedure. The patient tolerated the procedure well, was extubated in the operating room, and transferred to the recovery room in stable condition.
Findings
Acutely inflamed, thickened, nonperforated appendix consistent with acute suppurative appendicitis. No perforation, abscess, gangrene, appendicolith spillage, or generalized peritonitis was identified.
Specimen
Appendix submitted for permanent pathological examination.
Implants : None.
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44970 – Laparoscopy, surgical, appendectomy
Operative report 2
Preoperative Diagnosis
1. Acute appendicitis.
2. Extensive intra-abdominal adhesions with suspected adhesive disease from prior abdominal surgery.
Postoperative Diagnosis
1. Acute suppurative appendicitis.
2. Extensive dense intra-abdominal adhesions involving the anterior abdominal wall, cecum, terminal ileum, and right lower quadrant.
Procedure Performed
1. Laparoscopic extensive lysis of intra-abdominal adhesions.
2. Laparoscopic appendectomy.
Indication
The patient presented with worsening right lower quadrant abdominal pain, nausea, leukocytosis, and imaging findings consistent with acute appendicitis. The patient had a history of prior abdominal surgery with suspected adhesive disease. Laparoscopic appendectomy was recommended with the understanding that extensive adhesiolysis might be required to safely expose the appendix. Risks, benefits, and alternatives were discussed, and informed consent was obtained.
Description of the Procedure
The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Intravenous prophylactic antibiotics were administered, and sequential compression devices were applied. The abdomen was prepped and draped in the usual sterile fashion. A formal surgical time-out was performed.
A curvilinear infraumbilical incision was made, and pneumoperitoneum was established using an open Hasson technique because of the patient's prior abdominal surgery. Carbon dioxide insufflation was maintained at 15 mmHg. A 12-mm umbilical trocar was inserted, followed by placement of a 5-mm suprapubic trocar and a 5-mm left lower quadrant trocar under direct visualization.
Initial laparoscopic inspection revealed extensive dense fibrous adhesions between the anterior abdominal wall, greater omentum, terminal ileum, cecum, and right lower quadrant, completely obscuring visualization of the appendix. Safe access to the operative field was not possible without extensive adhesiolysis.
Meticulous laparoscopic lysis of adhesions was therefore performed using sharp dissection, blunt dissection, laparoscopic scissors, and a bipolar vessel-sealing device. Dense omental adhesions were separated from the anterior abdominal wall. Multiple adhesive bands involving the terminal ileum and cecum were carefully lysed while preserving bowel integrity. Additional adhesions tethering the cecum to the lateral abdominal wall were released to fully mobilize the cecum. Continuous inspection confirmed there was no bowel or vascular injury during the dissection.
The adhesiolysis required approximately 50 additional operative minutes beyond that normally required for a routine laparoscopic appendectomy due to the extensive adhesive disease and difficult exposure. Once the adhesions were completely released, the appendix became fully visible.
The appendix was markedly thickened, hyperemic, and acutely inflamed without evidence of perforation or abscess. The appendix was grasped at its tip and elevated. The mesoappendix was divided using a bipolar vessel-sealing device with secure control of the appendiceal artery. Dissection was continued to completely skeletonize the appendiceal base.
An endoscopic linear stapler was introduced through the umbilical trocar and positioned flush across the appendiceal base at its junction with the cecum. The stapler was fired, dividing the appendix while simultaneously creating a secure staple line. The appendiceal stump was inspected and demonstrated excellent hemostasis without bleeding or leakage.
The appendix was placed into an endoscopic specimen retrieval bag and removed through the umbilical trocar site without contamination.
The right lower quadrant and pelvis were copiously irrigated with warm normal saline and suctioned until clear. The operative field was carefully reinspected. The extensive adhesiolysis sites were evaluated and demonstrated excellent hemostasis without bowel injury. The appendiceal stump remained intact, and there was no enteric leakage.
A final survey of the abdominal cavity revealed no additional pathology. Pneumoperitoneum was evacuated under direct visualization, and all trocars were removed. The umbilical fascial defect was closed with interrupted 0-Vicryl sutures. Skin incisions were closed with running subcuticular 4-0 Monocryl sutures followed by skin adhesive. Sterile dressings were applied.
Instrument, sponge, and needle counts were correct at the completion of the procedure. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
Findings
Acute suppurative nonperforated appendicitis. Extensive dense adhesions involving the anterior abdominal wall, greater omentum, terminal ileum, cecum, and right lower quadrant, requiring extensive laparoscopic adhesiolysis before the appendix could be safely identified and removed.
Specimen
Appendix submitted for permanent pathological examination.
Implants
None.
Check your answer
44970 – Laparoscopic appendectomy.
Coding Note: Extensive laparoscopic adhesiolysis may support reporting 44180 (laparoscopic enterolysis) only if the adhesiolysis is performed for a separate pathologic condition, is significant and well beyond the exposure normally required for the appendectomy, and payer/NCCI rules allow separate reporting. If the adhesiolysis is performed solely to gain access to the appendix, it is generally considered integral to the appendectomy and is not separately reportable.
Operative report 3
Preoperative Diagnosis
1. Acute ruptured appendicitis.
2. Generalized peritonitis.
3. Localized periappendiceal abscess.
Postoperative Diagnosis
Same.
Procedure Performed
Open appendectomy with drainage of periappendiceal abscess and extensive peritoneal irrigation.
Indication
The patient presented with a several-day history of worsening right lower quadrant abdominal pain, fever, nausea, tachycardia, and leukocytosis. CT scan of the abdomen and pelvis demonstrated a ruptured appendix with periappendiceal abscess, inflammatory phlegmon, and localized peritonitis. Due to the perforated appendix with extensive inflammation, an open appendectomy was recommended. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
Description of the Procedure
The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Intravenous broad-spectrum antibiotics were administered, and sequential compression devices were applied. The abdomen was prepped and draped in the standard sterile fashion. A formal surgical time-out was performed.
A right lower quadrant Rocky-Davis incision was made and carried through the subcutaneous tissue using electrocautery. The external oblique fascia was incised in the direction of its fibers. The internal oblique and transversus abdominis muscles were bluntly separated, and the peritoneum was carefully entered.
Upon entering the peritoneal cavity, purulent fluid was immediately encountered and aspirated for culture. A localized periappendiceal abscess cavity was identified and completely evacuated. Dense inflammatory adhesions involving the cecum, terminal ileum, omentum, and surrounding tissues were carefully divided using blunt and sharp dissection to expose the appendix.
The appendix was identified as **ruptured and gangrenous**, with perforation involving the distal third of the appendix and surrounding inflammatory phlegmon. The appendix was mobilized circumferentially. The mesoappendix was sequentially clamped, divided, and ligated with 2-0 silk sutures while carefully controlling the appendiceal artery.
The base of the appendix was dissected free from the cecum. A crushing clamp was placed across the appendiceal base, followed by ligation with a 2-0 absorbable suture. The appendix was amputated and sent for pathological examination. The appendiceal stump mucosa was cauterized, and the stump was inverted into the cecum using a purse-string 3-0 silk suture, creating a secure closure. The stump was inspected and demonstrated no evidence of leakage.
The periappendiceal abscess cavity was thoroughly debrided of necrotic tissue and fibrinous debris. The right lower quadrant, pelvis, and paracolic gutter were copiously irrigated with several liters of warm normal saline until the effluent was completely clear. All contaminated fluid was suctioned from the abdominal cavity. A meticulous inspection confirmed excellent hemostasis without evidence of bowel injury.
Because of the perforation and abscess, a 19-French closed-suction drain was placed into the right lower quadrant adjacent to the appendiceal stump and brought out through a separate stab incision.
The peritoneum and muscle layers were reapproximated with absorbable sutures. The external oblique fascia was closed with running #1 PDS suture. The subcutaneous tissues were irrigated thoroughly. The skin was loosely approximated with staples, leaving spaces between staples to facilitate postoperative drainage due to the contaminated nature of the wound. Sterile dressings were applied.
Instrument, sponge, and needle counts were correct at the completion of the procedure. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
Findings
Ruptured gangrenous appendix with perforation of the distal appendix, localized periappendiceal abscess, extensive inflammatory phlegmon, purulent contamination of the right lower quadrant, and localized peritonitis. No diffuse fecal contamination or additional intra-abdominal pathology was identified.
Specimen
Ruptured appendix submitted for permanent pathological examination.
Drains
19-French closed-suction drain placed in the right lower quadrant adjacent to the appendiceal stump.
Implants
None.
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44960 – Appendectomy; for ruptured appendix with abscess or generalized peritonitis.
Operative report 4
Preoperative Diagnosis
1. Acute abdomen.
2. Suspected small bowel ischemia versus hollow viscus perforation.
Postoperative Diagnosis
Chronically diseased fibrotic appendix with chronic periappendiceal inflammation. No evidence of bowel ischemia or gastrointestinal perforation.
Procedure Performed
1. Exploratory laparotomy.
2. Incidental appendectomy.
Indication
The patient presented with severe diffuse abdominal pain, abdominal distention, guarding, rebound tenderness, leukocytosis, and elevated serum lactate concerning for bowel ischemia or perforated viscus. CT imaging demonstrated dilated small bowel loops with inflammatory changes but failed to identify a definitive source of the acute abdomen. Given the possibility of bowel ischemia or perforation requiring urgent surgical intervention, **exploratory laparotomy was medically necessary**. The patient was informed of the risks, benefits, and alternatives, and informed consent was obtained.
Description of the Procedure
The patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was induced. Broad-spectrum intravenous antibiotics were administered, and sequential compression devices were applied. The abdomen was prepped and draped in the standard sterile fashion. A formal surgical time-out was performed.
A midline laparotomy incision was made from above the umbilicus to the lower abdomen. The incision was carried through the subcutaneous tissue using electrocautery. The linea alba was divided, and the peritoneal cavity was entered under direct visualization.
A complete systematic exploration of the abdomen was performed. The stomach, duodenum, liver, gallbladder, spleen, small bowel from the ligament of Treitz to the ileocecal valve, colon, mesentery, and pelvis were thoroughly inspected. The small bowel was mildly dilated but remained viable throughout its entire length with normal color, peristalsis, and mesenteric arterial pulsations. No evidence of bowel ischemia, perforation, obstruction, mesenteric vascular compromise, intra-abdominal abscess, or generalized peritonitis was identified.
Attention was then directed to the right lower quadrant. The appendix was identified and found to be markedly thickened, fibrotic, indurated, and chronically scarred, with chronic inflammatory changes involving the mesoappendix and dense fibrosis surrounding its base. Although there was no acute purulent appendicitis, the appendix was clearly abnormal and represented the only significant intra-abdominal pathologic finding. Because of its chronically diseased appearance and the likelihood of future appendiceal complications, appendectomy was medically indicated.
The appendix was mobilized from the surrounding tissues. The mesoappendix was sequentially clamped, divided, and ligated with 2-0 silk sutures while securely controlling the appendiceal artery. The base of the appendix was circumferentially dissected free from the cecum. A crushing clamp was placed across the appendiceal base, followed by ligation with a 2-0 absorbable suture. The appendix was amputated and submitted for permanent pathological examination. The appendiceal stump mucosa was cauterized, and the stump was inverted into the cecum using a purse-string 3-0 silk suture. The repair was inspected and demonstrated excellent hemostasis without leakage.
The right lower quadrant and pelvis were irrigated with warm normal saline and suctioned dry. A final exploration of the abdominal cavity confirmed excellent hemostasis and no additional pathology requiring operative intervention.
The fascia was closed with a running #1 PDS suture. The subcutaneous tissues were irrigated, and the skin was closed with staples. Sterile dressings were applied.
Instrument, sponge, and needle counts were correct at the completion of the procedure. The patient tolerated the procedure well, was extubated in the operating room, and transferred to the recovery room in stable condition.
Findings
Complete abdominal exploration demonstrated **no bowel ischemia, bowel perforation, mesenteric vascular compromise, or other surgically correctable source of the acute abdomen**. The only abnormal finding was a **chronically fibrotic, indurated appendix with chronic inflammatory changes**, which warranted appendectomy.
Specimen
Appendix submitted for permanent pathological examination.
Implants
None.
Check your answer
49000 – Exploratory laparotomy (if separately reportable based on the overall operative scenario and payer/NCCI rules).
44955 – Appendectomy performed during another major abdominal procedure for an indicated abnormal appendix.
47564 – Laparoscopy, surgical; cholecystectomy with exploration of the common bile duct.
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