Operative Report Preoperative Diagnosis: Cholecystitis with…
Operative Report Preoperative Diagnosis: Cholecystitis with cholelithiasis Postoperative Diagnosis: Same Operative Procedure: Laparoscopic cholecystectomy Indications: A 77-year-old woman experiences upper abdominal pain and has been diagnosed with cholelithiasis. The risks and benefits of the procedure have been explained in detail. Technique: With the patient under general anesthesia, the abdomen was prepped and draped in the usual fashion. A small infraumbilical skin incision was made, carried down through the adipose tissue. The fascia was opened in the midline, and the peritoneal cavity under vision using laparoscopic technique. There was adequate insulfation of CO2. A 10-mm trocar was introduced into the upper abdomen to the right of the midline, two 55-mm trocars in the right upper quadrant area under directed camera vision. Examination noted that there were multiple adhesions in the gallbladder area. At this point, I was notified that the patient’s blood pressure was 150/80 and then dropped to 90/55. The blood pressure was stabilized but the decision was to abort the procedure at this time. All trocars were taken out under direct camera vision. The CO2 was desufflated. Infraumbilical incision was closed using 4-0 Vicryl subcuticular sutures, and Steri-Strips. She will be closely monitored and I will contact her primary care physician to discuss her condition. For hospital outpatient reporting, what is the correct code assignment?
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