Operative report Hepatic Procedure

Operative report 1

Preoperative Diagnosis

Indeterminate liver lesion requiring histopathologic diagnosis.

Postoperative Diagnosis

Indeterminate liver lesion; pathology pending.

Procedure Performed

Open wedge biopsy of the liver.

Indication

The patient was found to have an indeterminate hepatic lesion on cross-sectional imaging that could not be definitively characterized by noninvasive studies. Due to concern for neoplasm and the need for definitive histopathologic diagnosis, an open wedge liver biopsy 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 usual sterile fashion. A formal surgical time-out was performed.

A right subcostal (Kocher) incision was made and carried through the subcutaneous tissue using electrocautery. The anterior rectus sheath and abdominal wall musculature were divided, and the peritoneal cavity was entered under direct visualization. A self-retaining retractor was placed to provide adequate exposure.

The liver was systematically inspected and palpated. An indeterminate lesion was identified within the anterior aspect of the right hepatic lobe. The remaining liver surface was inspected for additional lesions or evidence of cirrhosis.

The liver surrounding the lesion was gently mobilized to optimize exposure. Stay sutures of 2-0 chromic were placed on either side of the planned biopsy site to facilitate hemostasis. Using a scalpel and electrocautery, a **full-thickness wedge biopsy** of the lesion with a small margin of adjacent normal hepatic parenchyma was sharply excised. The specimen measured approximately **2.0 × 1.5 × 1.0 cm** and was immediately sent for permanent pathological examination.

The biopsy bed was carefully inspected. Hemostasis was achieved using electrocautery, absorbable hemostatic material, and interrupted figure-of-eight 2-0 chromic sutures placed through the liver capsule and underlying parenchyma. The biopsy site was observed for several minutes and demonstrated complete hemostasis without evidence of bile leakage.

The operative field was irrigated with warm normal saline and suctioned dry. A final inspection confirmed excellent hemostasis and no additional hepatic bleeding.

The abdominal wall was closed in layers. The fascia was approximated with a running #1 PDS suture. The subcutaneous tissues were irrigated, and the skin was closed with a running subcuticular 4-0 Monocryl suture followed by sterile dressings.

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

Solitary indeterminate hepatic lesion involving the right hepatic lobe. No additional liver lesions or gross evidence of metastatic disease were identified. Hemostasis of the biopsy site was excellent without bile leakage.

Specimen

Open wedge biopsy of right hepatic lobe lesion submitted for permanent pathological examination.

Implants

None.

Check your answer

47100 – Biopsy of liver, wedge.

Operative report 2

Preoperative Diagnosis

Solitary left lateral hepatic lobe mass (Segments II and III), suspicious for hepatocellular adenoma.

Postoperative Diagnosis

Same.

Procedure Performed

Open left lateral segmentectomy (Segments II and III of the liver).

Indication

The patient was found to have a solitary 5.2 cm lesion involving the left lateral segment of the liver. Imaging characteristics were suspicious for hepatocellular adenoma with interval enlargement. Given the risk of hemorrhage and malignant transformation, surgical resection was recommended. 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 and venous thromboembolism prophylaxis were administered. The abdomen was prepped and draped in the usual sterile fashion. A formal surgical time-out was performed.

An upper midline incision with right subcostal extension (Mercedes-type exposure) was made. The subcutaneous tissues and fascia were divided using electrocautery, and the peritoneal cavity was entered under direct visualization. A self-retaining retractor was placed to provide adequate exposure.

The liver was systematically inspected and palpated. A solitary mass was identified within the **left lateral hepatic segment (Segments II and III)** without evidence of additional hepatic lesions or peritoneal metastases. Intraoperative palpation confirmed that the lesion was confined to the left lateral segment.

The falciform ligament was divided to the level of the suprahepatic inferior vena cava. The left triangular and left coronary ligaments were divided using a vessel-sealing device, completely mobilizing the left lateral segment. The ligamentum teres and ligamentum venosum were divided to facilitate mobilization.

The porta hepatis was exposed. The left hepatic pedicle supplying Segments II and III was carefully dissected. The segmental branches of the left hepatic artery and left portal vein to the left lateral segment were individually identified, doubly ligated, and divided. The corresponding left lateral segmental bile duct was identified, clipped, and divided. The vascular inflow to the left lateral segment was confirmed to be interrupted with clear demarcation of the planned line of transection.

The hepatic parenchymal transection line was marked with electrocautery. Parenchymal transection was performed using a combination of ultrasonic dissector, bipolar energy, and clamp-crushing technique. Small vascular and biliary radicals were individually clipped or ligated with absorbable sutures as encountered. Larger portal pedicles and hepatic venous tributaries were divided using vascular staplers where appropriate.

The left hepatic vein branch draining the left lateral segment was identified, controlled, and divided using a vascular stapling device. The specimen, consisting of **Segments II and III**, was completely detached and removed from the operative field. The resection specimen was oriented and submitted for permanent pathological examination.

The raw hepatic transection surface was meticulously inspected. Hemostasis was achieved using electrocautery, absorbable hemostatic agents, and interrupted figure-of-eight 3-0 Prolene sutures for small bleeding points. The biliary radicals were inspected, and no bile leakage was identified. The transection surface was observed for several minutes and remained completely hemostatic.

The operative field was irrigated with warm saline and suctioned dry. A closed-suction drain was placed adjacent to the hepatic transection surface and brought out through a separate stab incision.

The abdominal cavity was reinspected, confirming excellent hemostasis and no additional pathology. The fascia was closed with running #1 PDS sutures. 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

A solitary 5.2 cm mass confined to the left lateral hepatic segment (Segments II and III). No additional hepatic lesions, vascular invasion, or peritoneal metastatic disease were identified. Gross resection margins appeared negative.

Specimen

Left lateral hepatic segment (Segments II and III) containing hepatic mass submitted for permanent pathological examination.

Drains : One 19-French closed-suction drain placed adjacent to the hepatic transection surface.

Implants : None.

Check your answer

47125 – Hepatectomy; left lateral segmentectomy.

Operative report 3

Preoperative Diagnosis

Multiple hepatic metastases involving Segments II, III, IVA, and IVB.

Postoperative Diagnosis

Same.

Procedure Performed

Open multiple wedge resections of liver metastases.

Indication

The patient was diagnosed with multiple resectable hepatic metastases confined to the left hepatic lobe and segment IV on preoperative imaging. After multidisciplinary evaluation, the patient was deemed an appropriate candidate for parenchymal-sparing hepatic resection in order to achieve complete tumor removal while preserving maximal functional liver tissue. 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. An arterial line and appropriate intravenous access were established. 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.

An upper midline laparotomy incision was made and carried through the subcutaneous tissues using electrocautery. The fascia was divided, and the peritoneal cavity was entered under direct visualization. A self-retaining Thompson retractor was placed for optimal exposure.

The liver was completely inspected and palpated. The falciform ligament was divided to the level of the inferior vena cava. The left triangular ligament and coronary ligament were divided, allowing complete mobilization of the left hepatic lobe. The porta hepatis was exposed, and a vessel loop was placed around the hepatoduodenal ligament to allow intermittent **Pringle maneuver** occlusion during hepatic transection.

Intraoperative ultrasonography of the liver was performed, confirming multiple metastatic lesions confined to **Segments II, III, IVA, and IVB** without additional occult hepatic disease. The tumors were marked on the liver surface using electrocautery to define planned resection margins.

Attention was first directed to the **Segment III** lesion. Stay sutures were placed to facilitate retraction. During intermittent Pringle occlusion, hepatic parenchymal transection was performed using a combination of ultrasonic dissector (CUSA), bipolar energy device, and clamp-crushing technique. Small vascular and biliary radicals were controlled with clips or absorbable ligatures, while larger portal pedicles were divided using vascular staplers. The lesion was completely excised with a grossly negative margin.

The **Segment II** lesion was approached in a similar fashion. A wedge resection was performed while preserving as much uninvolved hepatic parenchyma as possible. Hemostasis and biliary control were maintained throughout the transection.

Separate wedge resections were then performed for metastatic lesions involving **Segment IVA** and **Segment IVB**. Each lesion was independently localized, circumferentially mobilized, and excised using the same parenchymal-sparing technique. Segmental vascular branches encountered during transection were individually clipped or divided using vascular staplers as appropriate. All specimens were labeled according to hepatic segment and submitted separately for permanent pathological examination.

Following completion of all four wedge resections, the hepatic resection surfaces were carefully inspected. Additional electrocautery was applied to the resection beds to ensure complete local tumor destruction at the margins. Meticulous hemostasis was achieved using electrocautery, absorbable hemostatic agents, and fibrin sealant. No active bleeding or bile leakage was identified.

The operative field was irrigated with warm saline and suctioned dry. A closed-suction drain was placed adjacent to the hepatic resection beds and brought out through a separate stab incision.

The abdominal fascia was closed with running #1 looped PDS sutures. 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

Four metastatic lesions were identified within **Segments II, III, IVA, and IVB** of the liver. No additional hepatic lesions, peritoneal metastases, or extrahepatic disease were identified. All lesions were successfully removed by non-anatomic wedge resections with preservation of the remaining hepatic parenchyma.

Specimens

1. Segment II liver wedge resection.

2. Segment III liver wedge resection.

3. Segment IVA liver wedge resection.

4. Segment IVB liver wedge resection.

Drains

One 19-French closed-suction drain adjacent to the hepatic resection beds.

Implants

None.

Check your answer

47122 – Hepatectomy, resection of liver; multiple wedge resections.

Operative report 4

Preoperative Diagnosis

1. Symptomatic cholelithiasis with chronic calculous cholecystitis.

2. Indeterminate liver lesion involving Segment V requiring histopathologic diagnosis.

Postoperative Diagnosis

Same.

Procedure Performed

1. Laparoscopic cholecystectomy.

2. Laparoscopic wedge biopsy of the liver.

Indication

The patient presented with recurrent right upper quadrant pain and imaging findings consistent with symptomatic cholelithiasis and chronic cholecystitis. Preoperative imaging also demonstrated an indeterminate 1.8 cm hepatic lesion within Segment V adjacent to the gallbladder fossa. Since the patient was already undergoing laparoscopic cholecystectomy, laparoscopic wedge biopsy of the liver lesion was recommended to establish a definitive histopathologic diagnosis. 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 a Veress needle. Carbon dioxide insufflation was maintained at 15 mmHg. A 12-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.

Initial exploration demonstrated a chronically inflamed gallbladder without evidence of perforation. A small indeterminate hepatic lesion was identified within **Segment V** near the gallbladder fossa.

The gallbladder fundus was retracted cephalad, and the infundibulum was retracted laterally to expose **Calot's triangle**. The peritoneum overlying the hepatocystic triangle was divided using electrocautery. Careful blunt and sharp dissection was continued until the **Critical View of Safety** was obtained, confirming that only the cystic duct and cystic artery entered the gallbladder.

The cystic artery was doubly clipped proximally, singly clipped distally, and divided. The cystic duct was similarly clipped and divided. The gallbladder was dissected from the liver bed using electrocautery in a retrograde fashion while maintaining meticulous hemostasis. The gallbladder was placed into an endoscopic retrieval bag and temporarily left within the abdominal cavity.

Attention was then directed to the hepatic lesion. The liver surrounding the lesion was inspected and mobilized as necessary to provide adequate exposure. Using electrocautery and laparoscopic ultrasonic shears, a **full-thickness wedge biopsy** incorporating the lesion with a small rim of surrounding normal hepatic parenchyma was sharply excised. The specimen measured approximately **2.0 × 1.5 cm** and was immediately retrieved in a separate specimen bag for permanent pathological examination.

The liver biopsy bed was carefully inspected. Hemostasis was achieved using bipolar electrocautery followed by application of absorbable hemostatic material and fibrin sealant. The biopsy site was observed for several minutes and demonstrated complete hemostasis without evidence of bile leakage.

The gallbladder specimen was then removed through the umbilical trocar site. The right upper quadrant was copiously irrigated with warm saline and suctioned dry. The gallbladder fossa, cystic duct stump, cystic artery clips, and liver biopsy site were carefully reinspected. Excellent hemostasis was present throughout, and no bile leakage was identified.

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. A solitary indeterminate **2 cm lesion within hepatic Segment V** was identified and excised by wedge biopsy. No additional hepatic lesions or evidence of metastatic disease were observed.

Specimens

1. Gallbladder with contents.

2. Wedge biopsy of Segment V liver lesion.

Implants

None.

Check your answer

47562 – Laparoscopic cholecystectomy.

47100 – Wedge biopsy of liver.

Operative report 5

Preoperative Diagnosis

Indeterminate liver lesion requiring tissue diagnosis.

Postoperative Diagnosis

Same.

Procedure Performed

Percutaneous core needle biopsy of the liver.

Indication

The patient was found to have an indeterminate hepatic lesion on cross-sectional imaging. A percutaneous core needle biopsy was recommended to establish a definitive histopathologic diagnosis. The risks, benefits, and alternatives, including bleeding, infection, bile leak, and injury to adjacent structures, were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the procedure suite and placed in the supine position. Moderate intravenous conscious sedation was administered, and continuous cardiac, blood pressure, and pulse oximetry monitoring was maintained throughout the procedure. The right upper abdomen was prepped with chlorhexidine solution and draped in the usual sterile fashion. A formal procedural time-out was performed.

Preprocedural ultrasound examination identified the previously noted hepatic lesion within the right hepatic lobe and confirmed a safe percutaneous access route free of intervening vascular structures. The skin and subcutaneous tissues were infiltrated with 1% lidocaine for local anesthesia.

A small skin nick was made with an #11 blade. Under continuous real-time ultrasound guidance, an 18-gauge core biopsy needle was advanced into the hepatic lesion. Needle position was confirmed prior to tissue acquisition. **Three adequate core biopsy specimens** were obtained using an automated biopsy device. Each specimen was immediately placed in formalin and submitted for permanent pathological examination.

Following specimen acquisition, the biopsy needle was removed. Manual pressure was applied over the puncture site for several minutes until complete hemostasis was achieved. A repeat ultrasound examination demonstrated no evidence of hemorrhage, subcapsular hematoma, or free intraperitoneal fluid.

A sterile adhesive dressing was applied. The patient tolerated the procedure well without immediate complications and was transferred to the recovery area for routine post-procedure observation with serial vital signs.

## Findings

Successful ultrasound-guided percutaneous core needle biopsy of an indeterminate right hepatic lobe lesion. Adequate tissue specimens were obtained without immediate procedural complications.

Specimens

Three core biopsy specimens from the right hepatic lobe lesion submitted for permanent pathological examination.

Implants

None.

Check your answer

• 47000 – Biopsy of liver, needle; percutaneous.

• 76942 – Ultrasonic guidance for needle placement (report separately when appropriate and documented).