Stomach surgery assistance?

[ksb0211]

Hoping for a little insight....Not sure if I'm coding this properly so I'd like a little input if possible. Thanks.

PROCEDURE/OPERATION
Exploratory laparotomy, repair of perforated stomach, biopsy of mesenteric lymph nodes, loop gastrojejunostomy.

DESCRIPTION OF PROCEDURE
The patient was taken to the O.R. after induction of adequate general anesthesia. The patient was prepped with DuraPrep and draped sterilely. Perioperative antibiotics had been administered.
The initial incision was made in the epigastrium in the midline. This was carried down to the subcutaneous tissues. Some free air was appreciated. No significant peritoneal soiling was noted. The stomach was noted to be markedly distended. Air bubbles were appreciated in the lesser omentum. The vasculature appeared markedly engorged consistent with some sort of portal hypertension, though the liver, itself, did not appear diseased. There is a large mass in the midline consistent with a pancreatic mass, neoplasm versus atypical severe pancreatitis.
The gallbladder was significantly distended. The lesser curve of the stomach was mobilized. Ultimately I was taking down the vasculature of the lesser curvature between clamps with suture ligatures of 2-0 silk. The Harmonic scalpel was unable to control bleeding from these vessels. The perforation was noted to be in the lesser curvature relatively high up. It was fairly well defined. After exposure it was noted to be approximately 3 cm in length and longitudinal. The stay sutures of 3-0 silk were placed, then 3-0 Vicryl suture was utilized and standard Lambert inverting suture was utilized followed by canal sutures of 3-0 silk.

Upon further examination of the abdominal cavity, it was extremely suspicious that there was a possibility of metastatic pancreatic carcinoma to the mesentery. Lymph node biopsies were obtained. Frozen section read by Dr. Alvarado failed to show metastatic disease. In spite of this I believe that the patient does manifest a gastric outlet obstruction. A loop gastrojejunostomy was then performed. The rent was made in the anti-colic omentum. The small bowel was brought up and then tacked to the stomach with interrupted 3-0 silk suture. Once this was done the GIA stapling device with green staples was passed. The enterotomy was closed with a TA-60 with green staples. Suture line was buried with 3-0 silk. Of note, any cuts or bleeding in the mesentery bled more than what would be typical. The vasculature all appeared to be engorged. Blood loss for the procedure was probably 400 mL. The abdominal cavity was then thoroughly irrigated. The loop gastrojejunostomy was secured with 3-0 Vicryl to the omentum. The midline incision was then closed with running double stranded #1 PDS. A 10 mm Jackson Pratt drain was placed. The patient tolerated the procedure.