Pre-procedure diagnosis:
Cholelithiasis, possible cholecystitis
Post-procedure diagnosis:
Cholelithiasis (K80.20) with obstruction (K80.21)
Cholelithiasis with acute cholecystitis (K80.00) and obstruction (K80.01)
Gangrene of gallbladder in cholecystitis (K82.A1)
Cholelithiasis with chronic cholecystitis (K80.10) and obstruction (K80.11)
Cholelithiasis with acute and chronic cholecystitis (K80.12) with obstruction (K80.13)
Cholelithiasis with other cholecystitis (K80.18) with obstruction (K80.19)
Cholelithiasis, choledocholithiasis with acute cholangitis (K80.32) and obstruction (K80.33)
Cholelithiasis, choledocholithiasis with chronic cholangitis (K80.34) and obstruction (K80.35)
Cholelithiasis, choledocholithiasis with acute and chronic cholangitis (K80.36) and obstruction (K80.37)
Cholelithiasis, choledocholithiasis, with acute cholecystitis (K80.42) with obstruction (K80.43)
Cholelithiasis, choledocholithiasis, with chronic cholecystitis (K80.44) with obstruction (K80.45)
Cholelithiasis, choledocholithiasis, with acute and chronic cholecystitis (K80.46) with obstruction (K80.47)
Acute acalculous cholecystitis (K81.0)
Chronic acalculous cholecystitis (K81.1)
Acute and chronic acalculous cholecystitis (K81.2)
Hydrops of gallbladder (K82.1)
Perforation of gallbladder (K82.2)
Fistula of gallbladder (K82.3)
Cholesterolosis of gallbladder (K82.4)
Biliary dyskinesia (non-functioning gallbladder) (K82.8)
Other diseases of gallbladder (K82.8)
Disease of gallbladder, unspecified (K82.9)
Biliary acute pancreatitis without necrosis or infection (K85.10)
Biliary acute pancreatitis with necrosis, without infection (K85.11)
Biliary acute pancreatitis with necrosis and infection (K85.12)
Umbilical hernia (K42.9)
Procedure Performed:
Laparoscopic cholecystectomy (47562) with cholangiogram (47563)
Umbilical hernia repair (49585)
Indication:
The patient presented with recurrent episodes of postprandial epigastric and right upper quadrant abdominal pain, associated with nausea and vomiting. Physical examination revealed tenderness in the right upper abdomen.
Laboratory studies were notable for leukocytosis and elevated liver enzymes. Abdominal ultrasound demonstrated cholelithiasis. A HIDA scan revealed non-visualization of the gallbladder, consistent with cystic duct obstruction.
These findings, along with the diagnosis, were thoroughly discussed with the patient. Management options were reviewed, including (1) conservative observation with dietary modification, (2) further diagnostic evaluation, such as additional imaging or gastroenterology consultation with possible endoscopy, and (3) definitive surgical intervention with cholecystectomy.
The risks of surgery were explained in detail, including but not limited to bleeding, infection, postoperative pain, bile leak, injury to the common bile duct, injury to adjacent structures (such as the intestine or duodenum), conversion to open procedure, anesthesia-related complications, and the possibility of retained stones or need for further intervention. The anticipated benefits of surgery were also discussed, including relief of current symptoms and prevention of future complications such as acute cholecystitis, choledocholithiasis, or gallstone-related pancreatitis.
The patient demonstrated clear understanding of the indications, alternatives, benefits, and risks of the procedure. After thoughtful consideration and opportunity to ask questions, the patient provided informed consent to proceed with cholecystectomy.
Operative Findings:
The gallbladder was distended and inflamed, with wall thickening, pericholecystic edema, and fibrotic adhesions consistent with acute-on-chronic cholecystitis.
Procedure Description:
After induction of general endotracheal anesthesia, the abdomen was prepared and draped in the standard sterile fashion. A universal protocol time-out was performed, verifying patient identity, planned procedure (laparoscopic cholecystectomy), surgical site, and confirmation of preoperative antibiotic administration.
A supraumbilical skin incision was created and extended to the anterior fascia. The fascia was elevated and incised under direct visualization, ensuring no adherent bowel. A 12-mm trocar was placed, and pneumoperitoneum was established with CO? insufflation to 15 mmHg. The laparoscope was inserted, and the initial entry site was inspected; no injury to bowel or viscera was identified.
Under laparoscopic guidance, three additional 5-mm trocars were placed along the right subcostal margin in the midclavicular, anterior axillary, and posterior axillary lines. The patient was positioned in reverse Trendelenburg with left lateral tilt to enhance exposure.
The gallbladder was noted to be inflamed and markedly distended. Omental and filmy adhesions were carefully lysed using a combination of blunt dissection with an atraumatic grasper and sharp dissection with electrocautery as required.
**[Optional decompression section:]**
Due to severe tense distension that impaired safe grasping and manipulation, the gallbladder was decompressed. A long aspiration needle was introduced through the midclavicular trocar, and bile was aspirated from the fundus under direct vision.
The gallbladder fundus was grasped via the most lateral trocar and retracted superolaterally. The infundibulum was grasped through the midclavicular trocar and retracted anteroinferiorly, establishing a clear critical view of safety within Calot's triangle.
Dissection commenced laterally with incision of the overlying peritoneum. The infundibulum was mobilized, and dissection advanced proximally to definitively identify the cystic duct–gallbladder junction. The cystic duct was circumferentially dissected free. Medial dissection then isolated the cystic artery, which was carefully mobilized while remaining in close proximity to the gallbladder to minimize risk to adjacent structures.
**[Optional cholangiogram section:]**
A polymer (Hem-o-lok) clip was placed on the cystic duct near the gallbladder neck. A limited cystic ductotomy was performed, and a cholangiogram catheter was inserted. Fluoroscopic imaging demonstrated normal opacification of the intra- and extrahepatic biliary tree, unrestricted flow of contrast into the
duodenum, and absence of filling defects or choledocholithiasis.
The cystic duct was secured with two Hem-o-lok clips proximally and one distally prior to division. The cystic artery was doubly clipped proximally and divided distally with electrocautery. The gallbladder was separated from the liver bed using hook electrocautery, with meticulous attention to hemostasis.
The specimen was placed into an endoscopic retrieval bag and extracted through the umbilical port site.
The gallbladder fossa and subhepatic space were copiously irrigated with warm saline and inspected for hemostasis.
**[Optional drain insertion:]**
A 19-French closed-suction drain was positioned in the subhepatic space and exteriorized through the most lateral trocar site.
All trocars were removed under direct vision, and port sites were inspected for bleeding. The 12-mm umbilical fascial defect was closed with interrupted figure-of-eight 0-Vicryl sutures. All port sites were infiltrated with local analgesic agent. Skin incisions were approximated with running subcutaneous 4-0 Monocryl sutures, and Dermabond tissue adhesive was applied.
The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.
**[Optional surgical assistance:]**
A qualified surgical assistant was present for the duration of the case and provided critical retraction, exposure, and tissue manipulation to ensure safe and effective completion of the operation.
Pre-procedure diagnosis:
Cholelithiasis, possible cholecystitis
Post-procedure diagnosis:
Cholelithiasis (K80.20) with obstruction (K80.21)
Cholelithiasis with acute and chronic cholecystitis (K80.12) with obstruction (K80.13)
Cholelithiasis with acute cholecystitis (K80.00) and obstruction (K80.01)
Gangrene of gallbladder in cholecystitis (K82.A1)
Cholelithiasis with chronic cholecystitis (K80.10) and obstruction (K80.11)
Cholelithiasis with other cholecystitis (K80.18) with obstruction (K80.19)
Cholelithiasis, choledocholithiasis with acute cholangitis (K80.32) and obstruction (K80.33)
Cholelithiasis, choledocholithiasis with chronic cholangitis (K80.34) and obstruction (K80.35)
Cholelithiasis, choledocholithiasis with acute and chronic cholangitis (K80.36) and obstruction (K80.37)
Cholelithiasis, choledocholithiasis, with acute cholecystitis (K80.42) with obstruction (K80.43)
Cholelithiasis, choledocholithiasis, with chronic cholecystitis (K80.44) with obstruction (K80.45)
Cholelithiasis, choledocholithiasis, with acute and chronic cholecystitis (K80.46) with obstruction (K80.47)
Acute acalculous cholecystitis (K81.0)
Chronic acalculous cholecystitis (K81.1)
Acute and chronic acalculous cholecystitis (K81.2)
Hydrops of gallbladder (K82.1)
Perforation of gallbladder (K82.2)
Fistula of gallbladder (K82.3)
Cholesterolosis of gallbladder (K82.4)
Biliary dyskinesia (non-functioning gallbladder) (K82.8)
Other diseases of gallbladder (K82.8)
Disease of gallbladder, unspecified (K82.9)
Biliary acute pancreatitis without necrosis or infection (K85.10)
Biliary acute pancreatitis with necrosis, without infection (K85.11)
Biliary acute pancreatitis with necrosis and infection (K85.12)
Umbilical hernia (K42.9)
Procedure Performed:
Robotic-assisted, laparoscopic cholecystectomy (47562)
with cholangiogram (47563)
Umbilical hernia repair (49585)
Indication:
The patient presented with recurrent episodes of postprandial epigastric and right upper quadrant abdominal pain, associated with nausea and vomiting. Physical examination revealed tenderness in the right upper abdomen. Laboratory studies were notable for leukocytosis and elevated liver enzymes. Abdominal ultrasound demonstrated cholelithiasis. A HIDA scan revealed non-visualization of the gallbladder, consistent with cystic duct obstruction. These findings, along with the diagnosis, were thoroughly discussed with the patient. Management options were reviewed, including (1) conservative observation with dietary modification, (2) further diagnostic evaluation, such as additional imaging or gastroenterology consultation with possible endoscopy, and (3) definitive surgical intervention with cholecystectomy.
The risks of surgery were explained in detail, including but not limited to bleeding, infection, postoperative pain, bile leak, injury to the common bile duct, injury to adjacent structures (such as the intestine or duodenum), conversion to open procedure, anesthesia-related complications, and the possibility of retained stones or need for further intervention. The anticipated benefits of surgery were also discussed, including relief of current symptoms and prevention of future complications such as acute cholecystitis, choledocholithiasis, or gallstone-related pancreatitis. The patient demonstrated clear understanding of the indications, alternatives, benefits, and risks of the procedure. After thoughtful consideration and opportunity to ask questions, the patient provided informed consent to proceed with cholecystectomy.
Operative Findings:
The gallbladder was distended and inflamed, with wall thickening, pericholecystic edema, and fibrotic adhesions consistent with acute-on-chronic cholecystitis.
Procedure Description:
Indocyanine green, 5 mg, was administered preoperatively before the patient was taken to the operating room. After induction of general endotracheal anesthesia, the abdomen was prepared and draped in the standard sterile fashion. A universal protocol time-out was performed, verifying patient identity, planned procedure (laparoscopic cholecystectomy), surgical site, and confirmation of preoperative antibiotic administration.
Initial abdominal access was obtained using an 8-mm optical trocar inserted at Palmer's point in the left upper quadrant via the Optiview technique. Pneumoperitoneum was established with CO? insufflation to 15 mmHg. The viscera at the entry site were inspected laparoscopically, revealing no injury from trocar placement. Under direct visualization, three additional 8-mm robotic trocars were placed: one at the umbilicus, one in the right flank, and one midway between these two ports.
The operating table was placed in 15-degree reverse Trendelenburg position with a slight leftward tilt. The da Vinci robotic system was then brought into the field, targeted, and docked. Instruments were introduced with bipolar forceps in arm 1, a 30-degree camera in arm 2, monopolar curved scissors in arm 3, and ProGrasp forceps in arm 4.
**[Intraoperative findings:]**
The gallbladder was noted to be inflamed and markedly distended. Omental and filmy adhesions were carefully lysed using a combination of blunt dissection with an atraumatic grasper and sharp dissection with electrocautery as required.
**[Optional decompression section:]**
Due to severe tense distension that impaired safe grasping and manipulation, the gallbladder was decompressed. A long aspiration needle was introduced through the midclavicular trocar, and bile was aspirated from the fundus under direct vision.
The gallbladder fundus was grasped via the most lateral trocar and retracted superolaterally. The infundibulum was grasped through the midclavicular trocar and retracted anteroinferiorly, establishing a clear critical view of safety within Calot's triangle.
Dissection commenced laterally with incision of the overlying peritoneum. The infundibulum was mobilized, and dissection advanced proximally to definitively identify the cystic duct–gallbladder junction. The cystic duct was circumferentially dissected free. Medial dissection then isolated the cystic artery, which was carefully mobilized while remaining in close proximity to the gallbladder to minimize risk to adjacent structures.
The cystic duct was secured with two Hem-o-lok clips proximally and one distally prior to division. The cystic artery was doubly clipped proximally and divided distally with electrocautery. The gallbladder was separated from the liver bed using hook electrocautery, with meticulous attention to hemostasis. The specimen was placed into an endoscopic retrieval bag and extracted through the umbilical port site.
All trocars were removed. The umbilical fascial defect was closed with interrupted figure-of-eight 0-Vicryl sutures. Skin incisions were approximated with running subcutaneous 4-0 Monocryl sutures, and Dermabond tissue adhesive was applied. The patient tolerated the procedure well and was transferred to the postanesthesia care unit in stable condition.
**[Optional surgical assistance:]**
A qualified surgical assistant was present for the duration of the case and provided critical retraction, exposure, and tissue manipulation to ensure safe and effective completion of the operation.
Pre-procedure diagnosis:
Ventral hernia
Post-procedure diagnosis:
Ventral hernia with obstruction, without gangrene (ICD10: K43.6) *** (often used for incarcerated ventral hernia without gangrene)
Ventral hernia with gangrene (ICD10: K43.7)
Ventral hernia without obstruction or gangrene (ICD10: K43.9
Incisional hernia with obstruction, without gangrene (ICD10: K43.0)
Incisional hernia with gangrene (ICD10: K43.1)
Incisional hernia without obstruction or gangrene (ICD10: K43.2)
Parastomal hernia with obstruction, without gangrene (ICD10: K43.3)
Parastomal hernia with gangrene (ICD10: K43.4)
Parastomal hernia without obstruction or gangrene (ICD10: K43.5)
Procedure Performed:
Laparoscopic ventral hernia repair, initial, less than 3cm, reducible (CPT 49591)
Laparoscopic ventral hernia repair, initial, less than 3cm, incarcerated (CPT 49592)
Laparoscopic ventral hernia repair, initial, 3-10cm, reducible (CPT 49593)
Laparoscopic ventral hernia repair, initial, 3-10cm, incarcerated (CPT 49594)
Laparoscopic ventral hernia repair, initial, greater than 10cm, reducible (CPT 49595)
Laparoscopic ventral hernia repair, initial, greater than 10cm, incarcerated (CPT 49596)
Laparoscopic ventral hernia repair, recurrent, less than 3cm, reducible (CPT 49613)
Laparoscopic ventral hernia repair, recurrent, less than 3cm, incarcerated (CPT 49614)
Laparoscopic ventral hernia repair, recurrent, 3-10cm, reducible (CPT 49615)
Laparoscopic ventral hernia repair, recurrent, 3-10cm, incarcerated (CPT 49616)
Laparoscopic ventral hernia repair, recurrent, greater than 10cm, reducible (CPT 49617)
Laparoscopic ventral hernia repair, recurrent, greater than 10cm, incarcerated (CPT 49618)
Findings:
A moderate-sized ventral hernia defect was identified in the midline anterior abdominal wall containing herniated omentum and a loop of small intestine. The incarcerated small bowel segment initially appeared dusky and dark red with questionable viability. After gentle reduction and 10–15 minutes of observation, the bowel regained normal pink color, demonstrated active peristalsis, and appeared fully viable. No other abdominal abnormalities were noted. No bowel perforation, peritonitis, or other visceral injury was present.
Indication:
The patient presented with a symptomatic ventral hernia containing incarcerated omentum and small bowel. Surgical repair was indicated due to incarceration and risk of bowel strangulation.
Description of the Procedure:
The patient was placed in the supine position. General endotracheal anesthesia was induced without complication. A Foley catheter was inserted. The abdomen was prepared and draped in sterile fashion. A surgical timeout was performed confirming patient identity, planned procedure, site, and administration of preoperative antibiotics.
Pneumoperitoneum was established using a 5-mm optical trocar placed at Palmer’s point in the left upper quadrant via the Optiview technique under direct visualization. No injury to underlying viscera occurred during entry. After confirming safe entry, two additional 5-mm trocars were inserted in the left mid- and lower quadrants under direct laparoscopic visualization.
The abdominal cavity was inspected. The findings is noted above. The incarcerated omentum and small bowel were carefully and gently reduced into the peritoneal cavity. A segment of small bowel that had been incarcerated initially appeared dusky and dark red. After reduction and 10–15 minutes of observation, the bowel recovered normal color and turgor with return of peristalsis. Viability was confirmed.
The fascial defect was measured (approximately [insert size in cm if known]). A composite mesh with anti-adhesion barrier was selected to provide at least 5 cm of overlap beyond the defect margins in all directions.
The mesh was rolled and introduced into the peritoneal cavity through the largest trocar site. Using the mesh positioning system, the center marking suture was passed through the anterior abdominal wall at the epicenter of the defect and secured. The mesh was then unfurled and oriented intraperitoneally. The mesh was fixated to the anterior abdominal wall using multiple absorbable tacks (AbsorbaTack™) in a double-crown configuration, ensuring secure circumferential fixation with appropriate overlap and no gaps.
Hemostasis was confirmed throughout the operative field. The abdomen was desufflated. All trocar sites were inspected under direct visualization and found to be hemostatic. The fascial defect at the optical entry site was closed with absorbable suture at the surgeon’s discretion. Skin incisions were closed with running subcuticular 4-0 Monocryl suture and sealed with Dermabond™.
Sponge, needle, and instrument counts were correct ×2. Estimated blood loss was minimal (<10 mL). No intraoperative complications occurred.
**[Optional surgical assistance:]**
A qualified surgical assistant was present for the duration of the case and provided critical retraction, exposure, and tissue manipulation to ensure safe and effective completion of the operation.
Pre-procedure diagnosis:
Acute appendicitis, unspecified
Post-procedure diagnosis:
Acute appendicitis with localized peritonitis without perforation or gangrene (ICD10: K35.30)
Acute appendicitis with generalized peritonitis, without perforation or abscess (ICD10: K35.200)
Acute appendicitis with generalized peritonitis and perforation, without abscess (ICD10: K35.201)
Acute appendicitis with generalized peritonitis and abscess, without perforation (ICD10: K35.210)
Acute appendicitis with generalized peritonitis, perforation, and abscess (ICD10: K35.211)
Acute appendicitis with localized peritonitis and gangrene, without perforation (ICD10: K35.31)
Acute appendicitis with localized peritonitis, perforation and gangrene, without abscess (ICD10: K35.32)
Acute appendicitis with localized peritonitis, perforation, gangrene, and abscess (ICD10: K35.33)
Unspecified acute appendicitis (ICD10: K35.80)
Procedure Performed:
Laparoscopic appendectomy (CPT 44970)
Indication:
The patient presented with right lower quadrant abdominal pain and tenderness on examination. CT scan findings were consistent with acute appendicitis.
The diagnosis and imaging findings were discussed in detail with the patient. Management options were reviewed, including nonoperative treatment with antibiotics versus definitive surgical management with appendectomy. The risks of surgery were explained, including bleeding, infection, injury to adjacent structures (small bowel, colon, bladder, or vessels), conversion to open procedure, anesthesia complications, and the potential need for further intervention. The benefits of surgery—resolution of current symptoms and prevention of recurrent or complicated appendicitis—were also outlined. The patient verbalized understanding of the indications, alternatives, risks, and benefits. All questions were answered, and informed consent was obtained for laparoscopic appendectomy.
Description of the Procedure:
The patient was placed in the supine position. General anesthesia was induced. The abdomen was prepped and draped in a sterile fashion. A time-out was completed verifying the correct patient, procedure, and administration of preoperative antibiotics. A supraumbilical incision was made and carried down to the fascia. The fascia was elevated and incised. Entry into the peritoneum was confirmed by direct vision. A 12-mm trocar was inserted, and the abdomen was insufflated to a pressure of 15 mmHg. The laparoscope was inserted. One 5-mm trocar was inserted in the left lower abdomen and another at the suprapubic, taking care to avoid injury to the bladder or inferior epigastric vessels. The table was placed in Trendelenburg position with the right side elevated.
The right lower quadrant was examined. The appendix was found inflamed. The base of the appendix was clearly located. The appendix and its mesentery were divided at the base using an endoscopic linear cutting stapler with a vascular load. The surgical site was inspected, and hemostasis was confirmed. The terminal ileum and cecum were inspected, and no other pathology was identified. The appendix was removed from the abdomen via the umbilical incision using an endoscopic retrieval bag.
The trocars were removed. The trocar sites were inspected to ensure hemostasis. The fascia at the umbilical incision was closed with interrupted figure-of-eight 0-Vicryl. Local anesthetic was infiltrated subcutaneously at the trocar sites. The skin was closed with subcuticular 4-0 Monocryl. Dermabond was applied. The patient tolerated the procedure well and was taken to the PACU in stable condition.
**[Optional surgical assistance:]**
A qualified surgical assistant was present for the duration of the case and provided critical retraction, exposure, and tissue manipulation to ensure safe and effective completion of the operation.
Pre-procedure diagnosis: Ischiorectal abscess
Post-procedure diagnosis: Ischiorectal abscess (ICD10: K61.39)
Procedure Performed: Incision and drainage of ischiorectal abscess (CPT: 46040)
Indication:
The patient presented with severe pain, swelling, and tenderness in the *** right/left ischiorectal fossa. *** Findings on imaging study is consistent with an ischiorectal abscess. Incision and drainage was indicated for source control and to prevent further sepsis or extension.
Operative Findings:
Procedure Description:
The patient was brought to the operating room and placed in the prone jackknife position after induction of general anesthesia. The perianal and gluteal regions were prepped and draped in a sterile fashion.
Local anesthesia (1% lidocaine with epinephrine) was infiltrated around the planned incision site. A generous elliptical incision was made over the point of maximal fluctuance in the ischiorectal fossa. A foul-smelling purulent material was immediately expressed and sent for aerobic/anaerobic culture and sensitivity.
The abscess cavity was explored bluntly with a finger, breaking up loculations and ensuring adequate drainage. No obvious fistula tract was identified at this time. The cavity was thoroughly irrigated with sterile saline solution. Hemostasis was achieved with direct pressure and electrocautery as needed. The wound was then loosely packed with 1-inch iodoform gauze to promote continued drainage and prevent premature closure. A sterile dressing was applied.
The patient tolerated the procedure well and was transferred to the recovery room in stable condition.