Operative report Cholecystectomy

Operative report 1

Preoperative Diagnosis

Symptomatic cholelithiasis with chronic calculous cholecystitis.

Postoperative Diagnosis

Same.

Procedure Performed

Laparoscopic cholecystectomy.

Indication

The patient presented with recurrent right upper quadrant pain, postprandial nausea, and intolerance to fatty meals. Abdominal ultrasound demonstrated multiple gallstones with findings consistent with chronic calculous cholecystitis. Conservative management failed to relieve symptoms, and elective laparoscopic cholecystectomy was recommended. The risks, benefits, alternatives, including possible bile duct injury and conversion to an open procedure, 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. Sequential compression devices were applied, and prophylactic intravenous antibiotics were administered. The abdomen was prepped and draped in the standard sterile fashion. A surgical time-out was performed.

A curvilinear infraumbilical incision was made, and pneumoperitoneum was established with a Veress needle. Carbon dioxide insufflation was achieved to an intra-abdominal pressure of 15 mmHg. A 10-mm umbilical trocar was inserted, and laparoscopic inspection confirmed safe abdominal entry without visceral or vascular injury. Under direct visualization, a 10-mm epigastric trocar and two 5-mm right subcostal trocars were inserted. The patient was placed in reverse Trendelenburg with the right side elevated.

The gallbladder fundus was grasped and retracted cephalad while the infundibulum was retracted laterally, exposing **Calot's (hepatocystic) triangle**. The peritoneal reflections overlying the cystic duct and cystic artery were incised using electrocautery. Careful blunt and sharp dissection was carried out to completely clear the fibrofatty tissue within Calot's triangle. The lower one-third of the gallbladder was dissected free from the cystic plate, and the cystic duct and cystic artery were circumferentially skeletonized.

The Critical View of Safety was obtained, confirming that only two tubular structures entered the gallbladder—the cystic duct and cystic artery—and that the hepatocystic triangle was completely cleared prior to division.

The cystic duct was secured with two proximal titanium clips and one distal clip before being divided. The cystic artery was similarly clipped with two proximal clips and one distal clip and then divided.

Using electrocautery, the gallbladder was carefully dissected from the hepatic fossa in a retrograde fashion. Small bleeding vessels encountered within the liver bed were coagulated as necessary to maintain meticulous hemostasis. The gallbladder was completely separated from the liver and placed into an endoscopic specimen retrieval bag.

The gallbladder fossa was irrigated with warm normal saline and suctioned dry. The liver bed was inspected and demonstrated excellent hemostasis without active bleeding. The cystic duct stump and cystic artery clips were secure, and there was no evidence of bile leakage or injury to the common bile duct or surrounding structures.

The specimen was removed through the umbilical trocar site. The umbilical fascial defect was closed with interrupted 0-Vicryl sutures. Pneumoperitoneum was evacuated under direct visualization, and all trocars were removed. Skin incisions were irrigated and closed with subcuticular 4-0 Monocryl sutures followed by skin adhesive. Sterile dressings were applied.

The patient tolerated the procedure well, was extubated in the operating room, and transferred to the post-anesthesia care unit in stable condition.

Findings

Chronically inflamed gallbladder containing multiple gallstones. Calot's triangle was successfully dissected, and the Critical View of Safety was obtained before clipping and dividing the cystic duct and cystic artery. No bile leak, common bile duct injury, or intraoperative complications were encountered.

Specimen

Gallbladder with contents submitted for permanent pathology.

Implants

None.

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CPT : 47562 - Laparoscopy Cholecystecomy

Operative report 2

Preoperative Diagnosis

Symptomatic cholelithiasis with chronic calculous cholecystitis; rule out choledocholithiasis.

Postoperative Diagnosis

Same.

Procedure Performed

Laparoscopic cholecystectomy with intraoperative cholangiography.

Indication

The patient presented with recurrent biliary colic, intermittent right upper quadrant pain, nausea, and elevated liver function tests concerning for possible choledocholithiasis. Ultrasound demonstrated cholelithiasis without definite common bile duct stones. Intraoperative cholangiography was planned to evaluate the biliary anatomy and exclude retained common bile duct calculi. The 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. Prophylactic intravenous 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 a Veress needle. Carbon dioxide insufflation was maintained at 15 mmHg. A 10-mm umbilical trocar was inserted, and diagnostic laparoscopy confirmed safe abdominal entry. Under direct visualization, a 10-mm epigastric trocar and two 5-mm right upper quadrant trocars were placed. The patient was positioned in reverse Trendelenburg with slight left lateral tilt.

The gallbladder fundus was retracted cephalad, and the infundibulum was retracted laterally to expose Calot's (hepatocystic) triangle. The peritoneum overlying the hepatocystic triangle was divided using electrocautery. Blunt and sharp dissection was performed to completely clear the fibrofatty tissue surrounding the cystic duct and cystic artery. The lower one-third of the gallbladder was separated from the cystic plate until the Critical View of Safety was obtained, confirming that only the cystic duct and cystic artery entered the gallbladder.

The cystic duct was circumferentially dissected. A distal clip was applied near the gallbladder, and a small transverse ductotomy was created in the cystic duct. A cholangiography catheter was introduced through a separate stab incision, advanced into the cystic duct, and secured with a clip.

Under fluoroscopic guidance, contrast ICG was injected into the biliary tree. The intraoperative cholangiogram demonstrated free flow of contrast through the common hepatic duct, common bile duct, and into the duodenum without filling defects. The right and left hepatic ducts were well visualized, and no evidence of choledocholithiasis, biliary obstruction, or ductal injury was identified. The catheter was removed after completion of the cholangiogram.

The cystic duct was then secured with two additional proximal titanium clips and divided. The cystic artery was isolated, clipped with two proximal clips and one distal clip, and divided.

Using electrocautery, the gallbladder was dissected from the liver bed in a retrograde fashion. Hemostasis was maintained throughout the dissection. The gallbladder was placed into an endoscopic retrieval bag and removed through the umbilical port.

The gallbladder fossa was irrigated with warm normal saline and suctioned dry. The liver bed demonstrated excellent hemostasis. The cystic duct stump and cystic artery clips were secure, and no bile leak was identified.

The umbilical fascial defect was closed with interrupted 0-Vicryl sutures. Pneumoperitoneum was released under direct visualization, and all trocars were removed. Skin incisions were closed with subcuticular absorbable sutures followed by skin adhesive. Sterile dressings were applied.

The patient tolerated the procedure well without complications, was extubated, and transferred to the recovery room in stable condition.

Findings

Chronically inflamed gallbladder containing multiple gallstones. Calot's triangle was completely dissected, and the Critical View of Safety was obtained. Intraoperative cholangiography demonstrated normal biliary anatomy with prompt contrast flow into the duodenum and no filling defects or evidence of common bile duct stones.

Specimen

Gallbladder with contents submitted for permanent pathology.

Implants

None.

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47563 – Laparoscopy Cholecystectomy with Cholangiography

Operative report 3

Preoperative Diagnosis

Acute calculous cholecystitis.

Postoperative Diagnosis

Acute gangrenous calculous cholecystitis with dense inflammatory adhesions.

Procedure Performed

Laparoscopic conversion to open cholecystectomy.

Indication

The patient presented with acute right upper quadrant abdominal pain, fever, leukocytosis, and imaging consistent with acute calculous cholecystitis. Operative management was recommended. The patient was counseled regarding the possibility of conversion to an open procedure should safe laparoscopic dissection not be feasible. 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 standard sterile fashion. A formal surgical time-out was performed.

A curvilinear infraumbilical incision was made, and pneumoperitoneum was established using a Veress needle. A 10-mm umbilical trocar was inserted, followed by placement of an epigastric 10-mm trocar and two 5-mm right upper quadrant trocars under direct visualization.

Initial laparoscopic inspection demonstrated a markedly distended, thick-walled gallbladder with dense omental adhesions. Adhesiolysis was carefully performed using blunt dissection and electrocautery to expose the gallbladder. The fundus was grasped and retracted cephalad while the infundibulum was retracted laterally in an attempt to expose Calot's (hepatocystic) triangle.

Despite meticulous dissection, severe inflammatory changes, dense fibrosis, and tissue edema obscured the normal anatomy. The cystic duct and cystic artery could not be safely identified, and the Critical View of Safety could not be obtained. Because continued laparoscopic dissection posed an unacceptable risk of common bile duct or vascular injury, the decision was made to convert to an open procedure.

Pneumoperitoneum was released, and the laparoscopic instruments were removed. A right subcostal (Kocher) incision was made, and the abdominal wall was divided in layers to enter the peritoneal cavity. A self-retaining retractor was placed for exposure.

The gallbladder was mobilized by carefully separating dense adhesions from the surrounding liver, duodenum, and transverse colon. Dissection was continued in the hepatocystic triangle until the cystic duct and cystic artery were individually identified. Each structure was circumferentially dissected, doubly ligated with silk ties, reinforced with clips as appropriate, and divided.

The gallbladder was then dissected from the liver bed using electrocautery. Small venous and arterial bleeding points within the gallbladder fossa were controlled with electrocautery and suture ligation. The liver bed was irrigated with warm normal saline and inspected. Excellent hemostasis was achieved, and no bile leak was identified.

The operative field was irrigated thoroughly. Because of the severe inflammation encountered, a closed-suction drain was placed in the gallbladder fossa and brought out through a separate stab incision.

The posterior fascia and muscle layers were closed with running absorbable sutures. The anterior fascia was closed with 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 operation well and was transferred to the recovery room in stable condition.

Findings

Markedly inflamed, thickened, gangrenous gallbladder containing multiple gallstones with dense inflammatory adhesions surrounding Calot's triangle. Safe laparoscopic identification of the biliary anatomy was not possible, necessitating conversion to an open cholecystectomy. The gallbladder was successfully removed without bile duct injury.

Specimen

Gallbladder with contents submitted for permanent pathology.

Drains

One closed-suction drain placed in the gallbladder fossa.

Implants

None.

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47600

Operative report 4

Preoperative Diagnosis

1. Symptomatic cholelithiasis with chronic calculous cholecystitis.

2. Reducible umbilical hernia.

Postoperative Diagnosis

Same.

Procedure Performed

1. Laparoscopic cholecystectomy.

2. Open primary repair of reducible umbilical hernia.

Indication

The patient presented with recurrent right upper quadrant pain, nausea, and intolerance to fatty foods. Ultrasound demonstrated multiple gallstones with findings consistent with chronic calculous cholecystitis. Elective laparoscopic cholecystectomy was recommended. During planned abdominal entry, a pre-existing reducible umbilical hernia was encountered at the intended umbilical trocar insertion site. The decision was made to utilize the hernia defect for laparoscopic access and perform definitive repair upon completion of the cholecystectomy.

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. A blunt Hasson trocar was inserted through the umbilical fascial defect and secured with stay sutures. Pneumoperitoneum was established with carbon dioxide to an intra-abdominal pressure of 15 mmHg. A laparoscope was introduced, confirming safe abdominal entry without evidence of visceral or vascular injury. Under direct visualization, a 10-mm epigastric trocar and two 5-mm right subcostal trocars were placed.

The patient was positioned in reverse Trendelenburg with slight left lateral tilt. The gallbladder fundus was grasped and retracted cephalad while the infundibulum was retracted laterally, exposing Calot's (hepatocystic) triangle. The peritoneum overlying the hepatocystic triangle was incised using electrocautery. Blunt and sharp dissection was carried out until all fibrofatty tissue was cleared from the triangle. The lower one-third of the gallbladder was separated from the cystic plate, allowing complete circumferential identification of the cystic duct and cystic artery.

The Critical View of Safety was obtained, confirming that only the cystic duct and cystic artery entered the gallbladder before any structures were divided.

The cystic duct was clipped with two proximal titanium clips and one distal clip before division. The cystic artery was similarly clipped with two proximal clips and one distal clip and then divided.

The gallbladder was dissected from the liver bed in a retrograde fashion using electrocautery. Small bleeding vessels encountered within the gallbladder fossa were coagulated as necessary. The gallbladder was completely detached and placed into an endoscopic retrieval bag. The specimen was removed through the umbilical incision.

The gallbladder fossa was irrigated with warm normal saline and suctioned dry. The liver bed demonstrated excellent hemostasis. The cystic duct stump and cystic artery clips were secure, and there was no evidence of bile leakage or injury to the common bile duct.

Dissection through the subcutaneous tissues revealed a reducible umbilical hernia at the planned trocar insertion site. Attention was then directed to the umbilical hernia repair. Pneumoperitoneum was released, and the Hasson trocar was removed. The hernia sac was completely mobilized from the fascial edges and excised. The fascial defect measured approximately 1.5 cm in greatest diameter. The fascial edges were refreshed, and the defect was closed primarily using interrupted figure-of-eight 0 Ethibond sutures, achieving a secure tension-free repair. The repair was inspected and found to be intact without residual fascial defect.

The umbilicus was reapproximated to the underlying fascia with absorbable sutures. The subcutaneous tissues were irrigated and closed with interrupted 3-0 Vicryl sutures. The skin of the umbilical incision and remaining trocar sites was closed with running subcuticular 4-0 Monocryl sutures followed by Dermabond. 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

Chronically inflamed gallbladder containing multiple gallstones. Calot's triangle was successfully dissected, and the Critical View of Safety was obtained before clipping and dividing the cystic duct and cystic artery. An umbilical hernia was identified at the umbilical trocar insertion site and was repaired primarily following completion of the laparoscopic cholecystectomy.

Specimens

Gallbladder with contents submitted for permanent pathology.

Implants

None.

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47562 : Laparoscopy , Cholecysteomy

The hernia repair at the site of cholecysteomy port incision such as umblical will not be reported seperately.

Operative report 5

Preoperative Diagnosis

Symptomatic cholelithiasis with chronic calculous cholecystitis.

Postoperative Diagnosis

Same.

Procedure Performed

Laparoscopic cholecystectomy with intraoperative indocyanine green (ICG) fluorescence

Indication

The patient presented with recurrent episodes of right upper quadrant abdominal pain, nausea, and intolerance to fatty meals. Imaging demonstrated multiple gallstones with findings consistent with chronic calculous cholecystitis. Elective laparoscopic cholecystectomy was recommended. The 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 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 15 mmHg. A 10-mm umbilical trocar was inserted, followed by placement of a 10-mm epigastric trocar and two 5-mm right subcostal trocars under direct laparoscopic visualization. Inspection confirmed safe abdominal entry without evidence of visceral or vascular injury.

The patient was positioned in reverse Trendelenburg with slight left lateral tilt. The gallbladder fundus was grasped and retracted cephalad while the infundibulum was retracted laterally to expose Calot's (hepatocystic) triangle. The peritoneum overlying the hepatocystic triangle was incised using electrocautery. Careful blunt and sharp dissection was performed to completely clear the fibrofatty tissue within the triangle. The lower one-third of the gallbladder was separated from the cystic plate, allowing circumferential identification of the cystic duct and cystic artery.

The Critical View of Safety was obtained, confirming that only the cystic duct and cystic artery entered the gallbladder before division.

The cystic duct was clipped with two proximal titanium clips and one distal clip before being divided. The cystic artery was similarly clipped with two proximal clips and one distal clip and then divided.

The gallbladder was dissected from the hepatic fossa in a retrograde fashion using electrocautery. Hemostasis was maintained throughout the dissection. The gallbladder was placed into an endoscopic specimen retrieval bag and removed through the umbilical port.

The gallbladder fossa was irrigated with warm normal saline and suctioned dry. The liver bed demonstrated excellent hemostasis, and the cystic duct stump and cystic artery clips remained secure.

Following completion of the cholecystectomy, Cholangiography was performed. Indocyanine green (ICG) fluorescence imaging was utilized with a near-infrared laparoscopic imaging system to evaluate the cystic duct stump, gallbladder fossa, and surrounding biliary structures for evidence of bile leakage. No fluorescence extravasation was identified. There was no evidence of bile leak from the cystic duct stump, liver bed, or accessory biliary ducts.

A final inspection confirmed excellent hemostasis and no injury to the common bile duct or surrounding structures. Pneumoperitoneum was released under direct visualization, and all trocars were removed.

The umbilical fascial defect was closed with interrupted 0-Vicryl sutures. The 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

Chronically inflamed gallbladder containing multiple gallstones. Calot's triangle was successfully dissected, and the Critical View of Safety was obtained before clipping and division of the cystic duct and cystic artery. Intraoperative ICG fluorescence imaging demonstrated **no evidence of bile leakage** from the cystic duct stump, gallbladder fossa, or accessory biliary ducts.

Specimen

Gallbladder with contents submitted for permanent pathology.

Implants

None.

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47562

ICG fluorescence imaging used only to evaluate for a bile leak is considered an adjunct to the laparoscopic cholecystectomy and is not separately reportable. This scenario still supports CPT 47562 (not 47563).

Operative report 6

Preoperative Diagnosis

1. Symptomatic cholelithiasis.

2. Suspected choledocholithiasis.

Postoperative Diagnosis

1. Chronic calculous cholecystitis.

2. Choledocholithiasis successfully treated.

Procedure Performed

Laparoscopic cholecystectomy with laparoscopic common bile duct exploration and extraction of common bile duct stone.

Indication

The patient presented with recurrent right upper quadrant pain, nausea, intermittent jaundice, and elevated liver function tests. Preoperative imaging demonstrated cholelithiasis with findings suspicious for common bile duct stones. Laparoscopic cholecystectomy with common bile duct exploration was recommended. The risks, benefits, alternatives, including the possibility of conversion to an open procedure, 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 a Veress needle. Carbon dioxide insufflation was maintained at 15 mmHg. A 10-mm umbilical trocar was inserted, followed by placement of a 10-mm epigastric trocar and two 5-mm right subcostal trocars under direct laparoscopic visualization.

The patient was positioned in reverse Trendelenburg with slight left lateral tilt. The gallbladder fundus was retracted cephalad, and the infundibulum was retracted laterally to expose Calot's (hepatocystic) triangle. The peritoneum overlying the hepatocystic triangle was divided using electrocautery. Blunt and sharp dissection was carried out until all fibrofatty tissue was cleared. The lower one-third of the gallbladder was separated from the cystic plate, and the Critical View of Safety was obtained.

The cystic artery was clipped with two proximal clips and one distal clip before division. The cystic duct was circumferentially dissected and controlled with a distal clip adjacent to the gallbladder. A longitudinal ductotomy was made in the cystic duct to permit access to the biliary tree.

A flexible choledochoscope was introduced through the cystic duct into the common bile duct. Systematic exploration of the common bile duct was performed. A single obstructing calculus was identified within the distal common bile duct. Under direct visualization, a stone retrieval basket was advanced through the choledochoscope, and the calculus was successfully captured and extracted through the cystic duct.

The common bile duct was re-examined with the choledochoscope. Copious saline irrigation was performed until the duct was completely clear. The proximal hepatic ducts and distal common bile duct were inspected and demonstrated no residual calculi, strictures, or obstruction. Free flow of irrigation into the duodenum confirmed ductal patency.

The choledochoscope was removed. The cystic duct was secured with additional titanium clips proximal to the ductotomy and divided.

The gallbladder was dissected from the liver bed using electrocautery in a retrograde fashion. Meticulous hemostasis was maintained throughout the dissection. The gallbladder was placed into an endoscopic specimen retrieval bag and removed through the umbilical port.

The gallbladder fossa and hepatoduodenal ligament were irrigated thoroughly with warm normal saline and suctioned dry. The liver bed demonstrated excellent hemostasis. The cystic duct stump and cystic artery clips were secure. No bile leakage was identified.

A final laparoscopic inspection confirmed satisfactory hemostasis and no evidence of injury to the common bile duct or surrounding structures. Carbon dioxide pneumoperitoneum was released 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, was extubated in the operating room, and transferred to the recovery room in stable condition.

Findings

Chronically inflamed gallbladder containing multiple gallstones. Calot's triangle was successfully dissected, and the Critical View of Safety was obtained. A single common bile duct stone was identified during laparoscopic choledochoscopy and successfully extracted. Completion exploration demonstrated a clear biliary tree with free flow into the duodenum and no residual calculi or bile leak.

Specimens

* Gallbladder with contents.

* Common bile duct stone (gross examination).

Implants :None.

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47564 – Laparoscopy, surgical; cholecystectomy with exploration of the common bile duct.

47564 – Laparoscopy, surgical; cholecystectomy with exploration of the common bile duct.