1. Operative Report PREOPERATIVE DIAGNOSIS: Biliary colic POSTOPERATIVE DIAGNOSI

Question

1. Operative Report PREOPERATIVE DIAGNOSIS: Biliary colic POSTOPERATIVE DIAGNOSIS: Biliary colic OPERATIVE PROCEDURE: 1. Laparoscopic Cholecystectomy with intraoperative cholangiogram 2. Tru-Cut liver biopsy ANESTHESIA: General DRAINS: None COMPLICATIONS: None ESTIMATED BLOOD LOSS: Minimal DETAILS: After the induction of general anesthesia, the patient's abdomen was prepped and draped sterilely. A small supraumbilical incision was created. The abdomen was entered. The peritoneal cavity was cannulated with a Veress needle. Position was confirmed with the drop test. The abdomen was insufflated to 250 mmHg with CO2 gas. A 5-mm trocar was placed under laparoscopic visualization. The laparoscope was introduced. Two 5-mm trocars were placed in the right flank. The patient was placed in reverse Trendelenburg position and rotated to the left. A 10-mm trocar was placed in the epigastrium. The fundus of the gallbladder was then grasped and retracted superolaterally. There were some adhesions in the midbody of the gallbladder that were mobilized away from the gallbladder. The infundibulum of the gallbladder was then grasped and retracted inferolaterally. The peritoneum overlying the cystic duct and cystic artery was then mobilized. The cystic duct and cystic artery were each isolated. Calot triangle was bluntly visualized. The artery was clipped proximally and distally. The duct was clipped to the level of the gallbladder and incised. This was then cannulated with the cholangiocatheter brought in through a separate port for the angiocath. A cholangiogram was obtained in real-time fluoroscopically and demonstrated normal biliary anatomy with free flow in the duodenum and no intraluminal filling defects. The catheter was then removed. The duct was clipped proximally and divided. The artery was divided. The gallbladder was then elevated from the gallbladder fossa with electrocautery. All bleeding points were controlled with electrocautery. There was excellent hemostasis. When the gallbladder dissection was completed, it was placed in an EndoCatch bag and removed through the epigastric trocar site. This was then sent to pathology for evaluation. The trocar was replaced in the right upper quadrant, and it was copiously irrigated until the effluent was clear. The trocars were then removed under laparoscopic visualization. There was excellent hemostasis. We then took four passes of the Tru-Cut needle to obtain a sample of the liver under direct laparoscopic visualization. The site was then cauterized with good hemostasis. The specimen was placed in formalin and sent for pathologic evaluation. The abdomen was irrigated. There was excellent hemostasis. The trocars were removed under laparoscopic visualization. Hemostasis was excellent. The abdomen was allowed to desufflate. The wounds were infiltrated with local anesthetic and closed with 4-0 Monocryl subcuticular sutures. Benzoin and Steri-strips were applied. A gauze and tape dressing was applied. The patient was then awakened and taken to the postanesthesia care unit in good condition having tolerated the procedure well.
Provide the following:
Final Code(s):
Name of Procedure:
Root Operation: (Index Main Term)
Body Part: (Index Sub-Term)
Approach:
Device:
Qualifier:
1. Operative Report PREOPERATIVE DIAGNOSIS: Biliary colic POSTOPERATIVE DIAGNOSIS: Biliary colic OPERATIVE PROCEDURE: 1. Laparoscopic Cholecystectomy with intraoperative cholangiogram 2. Tru-Cut liver biopsy ANESTHESIA: General DRAINS: None COMPLICATIONS: None ESTIMATED BLOOD LOSS: Minimal DETAILS: After the induction of general anesthesia, the patient's abdomen was prepped and draped sterilely. A small supraumbilical incision was created. The abdomen was entered. The peritoneal cavity was cannulated with a Veress needle. Position was confirmed with the drop test. The abdomen was insufflated to 250 mmHg with CO2 gas. A 5-mm trocar was placed under laparoscopic visualization. The laparoscope was introduced. Two 5-mm trocars were placed in the right flank. The patient was placed in reverse Trendelenburg position and rotated to the left. A 10-mm trocar was placed in the epigastrium. The fundus of the gallbladder was then grasped and retracted superolaterally. There were some adhesions in the midbody of the gallbladder that were mobilized away from the gallbladder. The infundibulum of the gallbladder was then grasped and retracted inferolaterally. The peritoneum overlying the cystic duct and cystic artery was then mobilized. The cystic duct and cystic artery were each isolated. Calot triangle was bluntly visualized. The artery was clipped proximally and distally. The duct was clipped to the level of the gallbladder and incised. This was then cannulated with the cholangiocatheter brought in through a separate port for the angiocath. A cholangiogram was obtained in real-time fluoroscopically and demonstrated normal biliary anatomy with free flow in the duodenum and no intraluminal filling defects. The catheter was then removed. The duct was clipped proximally and divided. The artery was divided. The gallbladder was then elevated from the gallbladder fossa with electrocautery. All bleeding points were controlled with electrocautery. There was excellent hemostasis. When the gallbladder dissection was completed, it was placed in an EndoCatch bag and removed through the epigastric trocar site. This was then sent to pathology for evaluation. The trocar was replaced in the right upper quadrant, and it was copiously irrigated until the effluent was clear. The trocars were then removed under laparoscopic visualization. There was excellent hemostasis. We then took four passes of the Tru-Cut needle to obtain a sample of the liver under direct laparoscopic visualization. The site was then cauterized with good hemostasis. The specimen was placed in formalin and sent for pathologic evaluation. The abdomen was irrigated. There was excellent hemostasis. The trocars were removed under laparoscopic visualization. Hemostasis was excellent. The abdomen was allowed to desufflate. The wounds were infiltrated with local anesthetic and closed with 4-0 Monocryl subcuticular sutures. Benzoin and Steri-strips were applied. A gauze and tape dressing was applied. The patient was then awakened and taken to the postanesthesia care unit in good condition having tolerated the procedure well.
Provide the following:
Final Code(s):
Name of Procedure:
Root Operation: (Index Main Term)
Body Part: (Index Sub-Term)
Approach:
Device:
Qualifier:
1. Operative Report PREOPERATIVE DIAGNOSIS: Biliary colic POSTOPERATIVE DIAGNOSIS: Biliary colic OPERATIVE PROCEDURE: 1. Laparoscopic Cholecystectomy with intraoperative cholangiogram 2. Tru-Cut liver biopsy ANESTHESIA: General DRAINS: None COMPLICATIONS: None ESTIMATED BLOOD LOSS: Minimal DETAILS: After the induction of general anesthesia, the patient's abdomen was prepped and draped sterilely. A small supraumbilical incision was created. The abdomen was entered. The peritoneal cavity was cannulated with a Veress needle. Position was confirmed with the drop test. The abdomen was insufflated to 250 mmHg with CO2 gas. A 5-mm trocar was placed under laparoscopic visualization. The laparoscope was introduced. Two 5-mm trocars were placed in the right flank. The patient was placed in reverse Trendelenburg position and rotated to the left. A 10-mm trocar was placed in the epigastrium. The fundus of the gallbladder was then grasped and retracted superolaterally. There were some adhesions in the midbody of the gallbladder that were mobilized away from the gallbladder. The infundibulum of the gallbladder was then grasped and retracted inferolaterally. The peritoneum overlying the cystic duct and cystic artery was then mobilized. The cystic duct and cystic artery were each isolated. Calot triangle was bluntly visualized. The artery was clipped proximally and distally. The duct was clipped to the level of the gallbladder and incised. This was then cannulated with the cholangiocatheter brought in through a separate port for the angiocath. A cholangiogram was obtained in real-time fluoroscopically and demonstrated normal biliary anatomy with free flow in the duodenum and no intraluminal filling defects. The catheter was then removed. The duct was clipped proximally and divided. The artery was divided. The gallbladder was then elevated from the gallbladder fossa with electrocautery. All bleeding points were controlled with electrocautery. There was excellent hemostasis. When the gallbladder dissection was completed, it was placed in an EndoCatch bag and removed through the epigastric trocar site. This was then sent to pathology for evaluation. The trocar was replaced in the right upper quadrant, and it was copiously irrigated until the effluent was clear. The trocars were then removed under laparoscopic visualization. There was excellent hemostasis. We then took four passes of the Tru-Cut needle to obtain a sample of the liver under direct laparoscopic visualization. The site was then cauterized with good hemostasis. The specimen was placed in formalin and sent for pathologic evaluation. The abdomen was irrigated. There was excellent hemostasis. The trocars were removed under laparoscopic visualization. Hemostasis was excellent. The abdomen was allowed to desufflate. The wounds were infiltrated with local anesthetic and closed with 4-0 Monocryl subcuticular sutures. Benzoin and Steri-strips were applied. A gauze and tape dressing was applied. The patient was then awakened and taken to the postanesthesia care unit in good condition having tolerated the procedure well.
Provide the following:
Final Code(s):
Name of Procedure:
Root Operation: (Index Main Term)
Body Part: (Index Sub-Term)
Approach:
Device:
Qualifier:

Explanation / Answer

Answer:-

1 .final code:- 47563 -cholecystectomy with cholangiogram

2. Name of procedure:- Laparoscopy, surgical; cholecystectomy with cholangiography

3. Root operation:- removal of gall bladder

4. Body part:- gall bladder in inferior surface of liver

5. Approach:-

Firstly, general anaesthesia, then a small supraumbilical incision => laparoscope was introduced=> Two 5-mm trocars were placed in the right flank => The fundus of the gallbladder was then grasped and retracted superolaterally
=> Calot triangle was bluntly visualized => A cholangiogram was obtained in real-time fluoroscopically => All bleeding points were controlled with electrocautery => cholecystectomy is done.

6. Device :- catheter cholangiography

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