Open Cholecystectomy

CPT 47600
Approach Open
Add-on / Variant CPTs
  • 47605 — With cholangiography
  • 47610 — With common bile duct exploration
Preoperative Diagnosis:

Acute cholecystitis / symptomatic cholelithiasis / gangrenous gallbladder

Postoperative Diagnosis:

Same

Procedure Performed:

Open cholecystectomy

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old [male/female] with a history of [indication] presenting for open cholecystectomy. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.

Findings:

The gallbladder was [distended/gangrenous/wall-thickened] with [clear/turbid/purulent/bilious] bile. [Dense adhesions were/were not] present in the hepatocystic triangle. [Pericholecystic inflammation was/was not] identified. The common bile duct measured approximately [___] cm in diameter. [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.

The abdomen was prepped and draped in sterile fashion. A right subcostal (Kocher) incision was made from the midline to the right lateral abdominal wall. The incision was carried through the skin, subcutaneous tissue, anterior rectus sheath, and rectus muscle. The peritoneal cavity was entered sharply. The abdomen was explored. A self-retaining retractor was placed for exposure.

The hepatocystic triangle was identified. The gallbladder fundus was grasped and retracted cephalad, and the infundibulum was retracted laterally. Adhesions were divided sharply and with electrocautery. The cystic duct and cystic artery were individually dissected, identified, doubly ligated with [2-0 silk] ties, and divided. The gallbladder was dissected from the liver bed with electrocautery proceeding from the infundibulum to the fundus. Hemostasis of the liver bed was achieved with electrocautery. The specimen was passed off the field.

The abdomen was irrigated with warm saline and inspected. Hemostasis was confirmed. No bile leak was identified. [A closed suction drain was/was not placed in the subhepatic space.] The fascial layers were closed with running [0-PDS] suture. The skin was closed with [staples/subcuticular 4-0 Monocryl]. Sterile dressings were applied.

Complications:

None

Specimens:

Gallbladder sent to pathology

Estimated Blood Loss:

Minimal (less than 50 mL)

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Open cholecystectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a history of *** presenting for open cholecystectomy. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.

FINDINGS: The gallbladder was ***. *** adhesions in the hepatocystic triangle. The common bile duct measured approximately *** cm.

DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, operative procedure, operative site, allergies, and administration of prophylactic antibiotics per protocol.

The abdomen was prepped and draped in sterile fashion. A right subcostal (Kocher) incision was made and carried through skin, subcutaneous tissue, anterior rectus sheath, rectus muscle, and peritoneum. The abdomen was explored and a self-retaining retractor was placed.

The hepatocystic triangle was identified. The gallbladder fundus was retracted cephalad and infundibulum laterally. Adhesions were divided. The cystic duct and cystic artery were individually identified, doubly ligated with 2-0 silk ties, and divided. The gallbladder was dissected from the liver bed with electrocautery. Hemostasis was confirmed. The specimen was passed off the field.

The abdomen was irrigated and inspected. No bile leak was identified. The fascia was closed with running 0-PDS suture. Skin was closed with ***. Sterile dressings were applied.

ESTIMATED BLOOD LOSS: ***
SPECIMENS: Gallbladder to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

With Intraoperative Cholangiogram

After proximal control of the cystic duct, a small cholecystotomy was made in the cystic duct and a cholangiogram catheter was inserted and secured with a ligaclip or tie. Fluoroscopic imaging was obtained demonstrating [normal biliary anatomy with free flow of contrast into the duodenum and no filling defects / filling defect at the level of the common bile duct / common bile duct dilation to ___ cm]. The catheter was removed, the cystic duct was ligated distally and divided.

Converted from Laparoscopic

The procedure was begun laparoscopically but was converted to open due to [dense adhesions/unclear biliary anatomy/bleeding/inability to achieve critical view of safety]. Trocar sites were closed and a right subcostal incision was made for adequate exposure. The procedure was then completed in open fashion as described above.

Gangrenous / Severely Inflamed Gallbladder

The gallbladder demonstrated gangrenous changes with [full-thickness necrosis/perforation/pericholecystic abscess]. The hepatocystic triangle was obliterated by inflammation. A fundus-first dissection was performed. The cystic duct was identified at the level of the common bile duct and ligated with [2-0 silk/0-Vicryl]. [A partial cholecystectomy was performed with oversewing of the cystic duct stump given concern for common bile duct injury with complete dissection.] The liver bed was inspected and irrigated. A closed suction drain was left in the subhepatic space.

Charting Tips
  • Document the specific reason for open approach (whether primary open or converted from laparoscopic). If converted, state clearly why (bleeding, unclear anatomy, inability to achieve CVS), as this has billing and medicolegal significance.
  • For gangrenous or perforated cases, document the extent of contamination, whether the abdomen was irrigated, and whether a drain was placed and why.
  • CBD diameter and cholangiogram results must be explicitly documented if obtained. 'Normal cholangiogram' is insufficient. Specify flow to duodenum, absence of filling defects, and duct diameter.
Billing Tips
  • Bill 47600 for open cholecystectomy (17.04 wRVU, 90-day global). Use for cholecystectomy performed open from the start or converted from laparoscopic.
  • Bill 47605 for open cholecystectomy with intraoperative cholangiogram (18.02 wRVU). Document contrast flow to the duodenum, CBD diameter, and absence of filling defects. The documentation requirements are the same as for 47563.
  • Do not bill both a laparoscopic code (47562) and an open code (47600) for a converted procedure. Bill only the open code when conversion occurs, and document the reason for conversion.
  • Open cholecystectomy wRVU (17.04) is substantially higher than laparoscopic (10.21), so code selection must match the actual approach. Upcoding a laparoscopic case as open is a common audit target.
  • 90-day global period: T-tube management, wound care, and routine follow-up are bundled. CBD exploration findings and any intraoperative drainage should be documented for postoperative management planning.