Laparoscopic Cholecystectomy
[Symptomatic cholelithiasis / Acute cholecystitis / Chronic cholecystitis / Gallstone pancreatitis / Biliary dyskinesia / Choledocholithiasis / Other]
Same
Laparoscopic cholecystectomy
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
The patient is a [age]-year-old [male / female] with [symptoms and diagnosis]. Evaluation demonstrated [ultrasound, CT, MRCP, HIDA, laboratory, or endoscopic findings]. The indication, operative and nonoperative options, and the possibility of cholangiography, subtotal cholecystectomy, conversion to an open operation, or additional biliary intervention were discussed as applicable. The risks, benefits, and alternatives were reviewed, and informed consent was obtained.
The gallbladder was [normal appearing / chronically inflamed / acutely inflamed]. The critical view of safety was achieved: the hepatocystic triangle was cleared of fat and fibrous tissue, the lower third of the gallbladder was separated from the liver to expose the cystic plate, and exactly two structures were seen entering the gallbladder.
The patient was positioned supine, and general endotracheal anesthesia was induced. A surgical time-out confirmed the patient, procedure, and administration of indicated prophylactic measures. The abdomen was prepared and draped in sterile fashion.
Peritoneal access was obtained at the umbilicus using [open Hasson technique / an optical trocar / a Veress needle]. Pneumoperitoneum was established, and an umbilical camera port and epigastric and right subcostal working ports were placed under direct vision. The patient was placed in reverse Trendelenburg with the right side elevated.
The gallbladder fundus was elevated, and the infundibulum was retracted to expose the hepatocystic triangle. Peritoneum was opened on the anterior and posterior aspects of the gallbladder neck, and fibrofatty tissue was cleared while maintaining dissection close to the gallbladder.
Dissection continued until all three components of the critical view of safety were present: the hepatocystic triangle was cleared, the lower third of the gallbladder was separated from the liver to expose the cystic plate, and exactly two structures entered the gallbladder. A momentary pause was taken to confirm these findings before division.
The cystic duct was [secured with clips on the biliary-tree and gallbladder sides and divided / ligated with an endoloop and divided / divided with an endoscopic linear stapler]. The cystic artery was secured with [clips / an energy device] and divided.
The gallbladder was separated from the cystic plate with electrocautery and placed in a retrieval bag. [No bile or stone spillage occurred. / Bile spilled and was suctioned, and all visible stones were retrieved.] The liver bed and ductal and arterial closures were inspected and were hemostatic without visible bile leakage. No drain was placed.
The specimen was removed through the umbilical port. Ports were removed under direct vision, and pneumoperitoneum was released. The fascia at ports 10 mm or larger was closed, and the skin incisions were closed. All counts were correct. The patient tolerated the procedure and was transferred to PACU in stable condition.
None
Gallbladder to pathology
[*** mL]
None
The patient was transferred to PACU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Symptomatic cholelithiasis / Acute cholecystitis / Chronic cholecystitis / Gallstone pancreatitis / Biliary dyskinesia / Choledocholithiasis / Other]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic cholecystectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [symptoms and diagnosis]. Evaluation demonstrated [findings]. Operative and nonoperative options and possible bailout procedures were discussed. The risks, benefits, and alternatives were reviewed, and informed consent was obtained.
FINDINGS: The gallbladder was [normal appearing / chronically inflamed / acutely inflamed]. The critical view of safety was achieved with all three criteria present.
DESCRIPTION OF PROCEDURE:
The patient was positioned supine, and general anesthesia was induced. A time-out confirmed the patient, procedure, and indicated prophylactic measures. The abdomen was prepared and draped sterilely.
Peritoneal access was obtained at the umbilicus using [open Hasson technique / an optical trocar / a Veress needle]. An umbilical camera port and epigastric and right subcostal working ports were placed under direct vision. The patient was placed in reverse Trendelenburg with the right side elevated.
The gallbladder was elevated, and the infundibulum was retracted. Peritoneum was opened anteriorly and posteriorly at the neck, and dissection remained close to the gallbladder. The hepatocystic triangle was cleared, the lower third of the gallbladder was separated from the liver to expose the cystic plate, and exactly two structures entered the gallbladder. A momentary pause confirmed the critical view before division.
The cystic duct was [secured with clips on the biliary-tree and gallbladder sides and divided / ligated with an endoloop and divided / divided with an endoscopic linear stapler]. The cystic artery was secured with [clips / an energy device] and divided. The gallbladder was separated from the liver with electrocautery and placed in a retrieval bag. [No bile or stone spillage occurred. / Bile spilled and was suctioned, and all visible stones were retrieved.] The liver bed and ductal and arterial closures were hemostatic without visible bile leakage. No drain was placed.
The specimen was removed through the umbilical port. Ports were removed under direct vision, and pneumoperitoneum was released. The fascia at ports 10 mm or larger and the skin incisions were closed. All counts were correct. The patient tolerated the procedure and was transferred to PACU in stable condition.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Gallbladder to pathology [and ***]
COMPLICATIONS: None
DRAINS: [None / ***]
DISPOSITION: PACU in stable condition
Signed: .ME, .MYDEGREE
.TODAYVariants
Intraoperative cholangiography
After the cystic duct was identified, a clip was placed on the gallbladder side of the intended ductotomy. A ductotomy was created, and a [catheter type] was advanced toward the common duct and secured with [method]. After flushing the catheter and excluding leakage, contrast was injected under fluoroscopy. Imaging demonstrated [right and left hepatic ducts / common hepatic duct / common bile duct], [free passage into the duodenum / absent or delayed passage], [no filling defects / filling defect at ***], and [no extravasation / extravasation at ***]. [Additional views, glucagon, flushing, stone extraction, consultation, or other action was performed because ***.] The catheter was removed. The cystic duct was [secured on the biliary-tree side with clips, an endoloop, or suture and divided / divided on the biliary-tree side with an endoscopic linear stapler].
Acute cholecystitis or gangrenous gallbladder
The gallbladder was [distended / thick-walled / gangrenous / perforated] with [hydrops / purulent or bilious contents / pericholecystic fluid] and [omental / duodenal / colonic] adhesions. [Needle decompression yielded ***.] Adhesions were divided using [technique], and friable tissue or contamination was managed with [technique]. The dissection required [additional time or maneuvers] because [edema / fibrosis / inflammatory fusion / bleeding / tissue friability]. [All three critical-view criteria were ultimately achieved and the routine total operation was completed / The critical view was not achieved, no uncertain structure was divided, and the subtotal or conversion module was used.] [Bile was sent for culture / No culture was obtained.] [Spillage, stone retrieval, irrigation, and drain decision.]
Dome-down or fundus-first dissection
Because [reason], a fundus-first approach was selected. The gallbladder was separated from the cystic plate beginning at the fundus and proceeding toward the infundibulum, with dissection maintained on the gallbladder wall and stopped at [level]. [Safe anatomy was ultimately established, all three critical-view criteria were confirmed, and the identified cystic duct and artery were secured and divided / Anatomy remained unclear near the infundibulum, further total-cholecystectomy dissection was abandoned, and the subtotal module was used.] Document any gallbladder entry, bleeding, altered anatomy, and additional biliary imaging.
Subtotal cholecystectomy bailout (fenestrating or reconstituting)
Marked [acute inflammation / chronic fibrosis / inflammatory fusion / bleeding / other] prevented safe clearance of the hepatocystic triangle and identification of the cystic duct and artery. The critical view of safety was not achieved. Further dissection in the unsafe area was stopped, and no unidentified ductal or arterial structure was divided. [A second surgeon was consulted / Intraoperative biliary imaging was used as follows / Other safety assessment.] The gallbladder was opened on its anterior surface at the [fundus / body] safely away from the porta. [Bile / pus] was evacuated, and all visible stones were removed and placed in a retrieval bag. The free wall was excised from the fundus toward the infundibulum to the lowest level considered safe. The posterior wall was [left attached to the cystic plate / partially excised / completely excised]. Residual mucosa that could be treated safely was [cauterized / left untreated because ***], avoiding thermal injury near the porta or suspected cystic-duct orifice. [Fenestrating technique: the gallbladder remnant was left open. The internal cystic-duct orifice was [clearly identified and closed internally with *** / not safely identifiable, and no blind closure was attempted / intentionally left open because ***]. / Reconstituting technique: the remnant was inspected to confirm removal of visible stones and was closed with [running or interrupted suture / an endoscopic linear stapler / an endoloop] at [level], creating a closed remnant; the cystic duct was not separately dissected.] Hemostasis was achieved, and bile egress from the remnant was [absent / present as described]. The resected wall and stones were bagged, and [spillage and retrieval] were documented. [A [type and size] drain was left in the gallbladder fossa through [site] and secured with [suture] / No drain was placed because ***.]
Conversion to open cholecystectomy
After laparoscopic assessment and [maneuvers attempted], the operation was converted to an open approach because [uncertain anatomy / inflammatory fusion / bleeding / suspected injury / equipment limitation / other]. Conversion occurred before [duct or artery division / step] and was undertaken to obtain safer exposure and control. A [right subcostal / upper midline] incision was made. The completed open procedure was [total cholecystectomy / fenestrating subtotal cholecystectomy / reconstituting subtotal cholecystectomy / exploration and drainage / other]. Document how the biliary anatomy was established, how the cystic duct or remnant and artery were managed, any cholangiography or consultation, hemostasis, drain placement, and fascial closure. Do not state that the critical view was achieved unless all three criteria were actually demonstrated.
Charting Tips
- The critical view of safety requires clearance of the hepatocystic triangle, separation of the lower third of the gallbladder from the liver to expose the cystic plate, and exactly two structures entering the gallbladder.
- If the critical view was not achieved, use a bailout variant and document why routine dissection stopped without dividing an uncertain ductal or arterial structure.
- For cholangiography, document the visualized ducts, duodenal flow, filling defects, extravasation, and response to abnormal findings.
- For subtotal cholecystectomy, name the fenestrating or reconstituting technique and document retained wall, remnant or cystic-duct-orifice management, stone clearance, bile egress, and drain decision.
- For conversion, record the reason, stage of conversion, completed open operation, and management of the ductal anatomy and gallbladder remnant.
- Document any bile or stone spillage, retrieval efforts, irrigation when performed, final hemostasis, visible bile leakage, and drain placement or omission.
Documentation & Reimbursement Considerations
- Report Laparoscopic Cholecystectomy as the primary service when it is the definitive operation performed.
- Laparoscopic gallbladder removal without biliary imaging or duct exploration, with intraoperative cholangiography, and with common-bile-duct exploration are distinct reporting categories. Document the work actually performed.
- When cholangiography is performed, record the cannulation technique, visualized ductal anatomy, passage of contrast into the duodenum, filling defects or extravasation, and any action taken.
- For common-bile-duct exploration, document the indication, transcystic or choledochotomy approach, instruments used, findings, stone extraction, and method used to assess duct clearance.
- These laparoscopic cholecystectomy services generally carry a 90-day Medicare global period.
- When an operation is converted, document the reason and the completed open procedure. The unsuccessful laparoscopic portion is not a separate additional service.
- If the operative work substantially exceeds a routine cholecystectomy, describe the inflammation, distorted anatomy, additional maneuvers, time, and risk rather than relying only on the word difficult.