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PATIENT: Margaret Hill
ATTENDING PHYSICIAN: Ronald Green, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Chronic cholecystitis and cholelithiasis
POSTOPERATIVE DIAGNOSIS: Chronic cholecystitis and cholelithiasis
PROCEDURE PERFORMED: Laparoscopic cholecystectomy
INDICATION: Mrs. Hill has been having RUQ pain with nausea and vomiting and diarrhea. The patient was found to have chronic cholecystitis with cholelithiasis and she was taken to the operating room.
PROCEDURE: The patient received Ancef 1 gram intravenously preoperatively. She was prepped and draped in the usual manner. An infra umbilical incision was made; the abdomen was entered under direct vision. Two stay sutures of 0 Vicryl were placed on either side of the incision. The Hasson sheath was then inserted. The abdomen was then inflated with CO2 gas. Three additional ports were then placed. The hilum of the gallbladder was then dissected free. The cystic duct and cystic arteries were identified. The cystic duct was clipped with three white clips and divided. The cystic arteries were clipped with three white clips and divided. There was another small branch of the artery encountered up on the gallbladder bed. This was also clipped with three white clips and divided. The gallbladder was then dissected free from the gallbladder bed using hook cautery. The specimen was placed in a bag and brought out through a lateral port. The
lateral port fascia was approximated with 0 Vicryl sutures. The operative area was thoroughly irrigated and the incisions were then closed with 3-0 Vicryl sutures for the subcutaneous tissues and a 4-0 Vicryl subcuticular stitch for the skin. Steri-Strips were
applied. Incisions were then injected with 0.5% Marcaine with Epinephrine. The patient tolerated the operation and returned to Recovery in stable condition.
Identify the correct diagnosis (ICD-9-CM) code(s) for the inpatient hospital visit for patient Margaret Hill