lindacoder
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ANESTHESIA: General with local.
PREOPERATIVE DIAGNOSIS: Status post BPD with DS with recurrent abdominal pain. Malnourishment.
POSTOPERATIVE DIAGNOSIS: Same with suprapubic incisional hernia.
OPERATION PERFORMED: Diagnostic laparoscopy, lengthening of common channel, repair of suprapubic hernia with Ventralex mesh.
INDICATIONS FOR PROCEDURE: The patient is a 62-year-old female who I did a BPD with DS in 10/2012. She has had trouble with significant weight loss and then inability to maintain. She has also been having abdominal pain intermittently. She does have significant constipation. EGD and colonoscopy other than redundant colon was unremarkable. She now is to undergo a diagnostic laparoscopy to rule out internal hernia or other hernia as well. Also because of this extreme weight loss will also plan on making her common channel longer by 100 to 150 cm.
DESCRIPTION OF PROCEDURE: In the supine position, the abdomen was prepped and draped in the usual fashion. After anesthetizing with 0.25% Marcaine, a left upper quadrant incision was made. Under direct visualization, a 5 mm Optiview port was placed. The abdomen was insufflated with 15 cm of pressure. An additional 10 mm port was placed in the left periumbilical location and a 5 mm in the right lower quadrant. I identified the cecum. On exam, she did have a very redundant colon with a large amount of stool still present. Of note, she had a previous hysterectomy, appendectomy, cholecystectomy. I ran her ileum to her ileal anastomosis that was about 160 cm. Her common channel was about 160 cm. Her Roux limb was about 100 cm. I then ran her biliopancreatic limb and it was about 640 cm which probably accounts for why she had such extreme weight loss due to that significant bypass portion there. I therefore felt it best to add about another 150 cm back in to make it about 300 cm long. I therefore marked on the Roux limb about 50 cm up from the previous anastomosis and then ran about 100 cm proximal on the biliopancreatic limb and marked both areas with clips. It should be noted that I looked at her previous ileostomy, and there was no evidence of an internal hernia or Peterson's defect. I then made an opening on that area that had been marked and did a side-to-side stapled anastomosis with two white loads with the Echelon and then closing the opening with an Echelon white load. With this, the anastomosis was widely patent. I then closed that mesenteric defect with a running 2-0 silk. This should effectively make her common channel about 300 cm but still leave about 500 cm bypass/ I think she will still have good weight loss but hopefully less nutritional issues. On looking around I saw there was down in her suprapubic location a little bit off to the right a small incisional hernia from her previous hysterectomy. I therefore went ahead after anesthetizing and made an incision over this. I dissected this area to the preperitoneal space, and then placed a medium Ventralex mesh to lie and close this completely. With doing this, I did get a little peritoneal opening which I closed with a running 2-0 Vicryl intracorporeally. I then approximated that deep tissues with running 2-0 Vicryl incorporating the mesh after cutting off the straps. With completion, I closed that defect very nicely. There are no other hernias. After ensuring hemostasis there were 2 little small serosal tears on the right colon which was approximated with figure-of-eight 2-0 silk. No other abnormalities were seen. The area was irrigated and irrigation was removed. The instruments and ports were removed. That 10 mm port fascia was closed with interrupted 2-0 Vicryl, deep tissues in the lower suprapubic location was closed with running 2-0 Vicryl, skin edges were closed with running 4-0 Monocryl subcuticular stitch. Steri-Strips and a sterile dressing were applied.
ESTIMATED BLOOD LOSS: Minimal.
Sponge and needle counts were correct. She tolerated the procedure and was taken to the recovery room in satisfactory condition.
Pt has Medicare so and there is no laparoscopic code for this so I know it will have to be unlisted 43659 but wondered about the comparative open code. Looking at 43860 but no sure about that. Will also do lap incisional hernia repair 49654.
Any input is appreciated.
PREOPERATIVE DIAGNOSIS: Status post BPD with DS with recurrent abdominal pain. Malnourishment.
POSTOPERATIVE DIAGNOSIS: Same with suprapubic incisional hernia.
OPERATION PERFORMED: Diagnostic laparoscopy, lengthening of common channel, repair of suprapubic hernia with Ventralex mesh.
INDICATIONS FOR PROCEDURE: The patient is a 62-year-old female who I did a BPD with DS in 10/2012. She has had trouble with significant weight loss and then inability to maintain. She has also been having abdominal pain intermittently. She does have significant constipation. EGD and colonoscopy other than redundant colon was unremarkable. She now is to undergo a diagnostic laparoscopy to rule out internal hernia or other hernia as well. Also because of this extreme weight loss will also plan on making her common channel longer by 100 to 150 cm.
DESCRIPTION OF PROCEDURE: In the supine position, the abdomen was prepped and draped in the usual fashion. After anesthetizing with 0.25% Marcaine, a left upper quadrant incision was made. Under direct visualization, a 5 mm Optiview port was placed. The abdomen was insufflated with 15 cm of pressure. An additional 10 mm port was placed in the left periumbilical location and a 5 mm in the right lower quadrant. I identified the cecum. On exam, she did have a very redundant colon with a large amount of stool still present. Of note, she had a previous hysterectomy, appendectomy, cholecystectomy. I ran her ileum to her ileal anastomosis that was about 160 cm. Her common channel was about 160 cm. Her Roux limb was about 100 cm. I then ran her biliopancreatic limb and it was about 640 cm which probably accounts for why she had such extreme weight loss due to that significant bypass portion there. I therefore felt it best to add about another 150 cm back in to make it about 300 cm long. I therefore marked on the Roux limb about 50 cm up from the previous anastomosis and then ran about 100 cm proximal on the biliopancreatic limb and marked both areas with clips. It should be noted that I looked at her previous ileostomy, and there was no evidence of an internal hernia or Peterson's defect. I then made an opening on that area that had been marked and did a side-to-side stapled anastomosis with two white loads with the Echelon and then closing the opening with an Echelon white load. With this, the anastomosis was widely patent. I then closed that mesenteric defect with a running 2-0 silk. This should effectively make her common channel about 300 cm but still leave about 500 cm bypass/ I think she will still have good weight loss but hopefully less nutritional issues. On looking around I saw there was down in her suprapubic location a little bit off to the right a small incisional hernia from her previous hysterectomy. I therefore went ahead after anesthetizing and made an incision over this. I dissected this area to the preperitoneal space, and then placed a medium Ventralex mesh to lie and close this completely. With doing this, I did get a little peritoneal opening which I closed with a running 2-0 Vicryl intracorporeally. I then approximated that deep tissues with running 2-0 Vicryl incorporating the mesh after cutting off the straps. With completion, I closed that defect very nicely. There are no other hernias. After ensuring hemostasis there were 2 little small serosal tears on the right colon which was approximated with figure-of-eight 2-0 silk. No other abnormalities were seen. The area was irrigated and irrigation was removed. The instruments and ports were removed. That 10 mm port fascia was closed with interrupted 2-0 Vicryl, deep tissues in the lower suprapubic location was closed with running 2-0 Vicryl, skin edges were closed with running 4-0 Monocryl subcuticular stitch. Steri-Strips and a sterile dressing were applied.
ESTIMATED BLOOD LOSS: Minimal.
Sponge and needle counts were correct. She tolerated the procedure and was taken to the recovery room in satisfactory condition.
Pt has Medicare so and there is no laparoscopic code for this so I know it will have to be unlisted 43659 but wondered about the comparative open code. Looking at 43860 but no sure about that. Will also do lap incisional hernia repair 49654.
Any input is appreciated.