44604

KBean2018

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Hello, does anyone see 44604 (suture in large instestine) in the below procedure? I cannot locate supporting documentation.

A limited upper midline incision was made with #10 blade. Soft tissue was dissected down to the fascia with electrocautery. Fascia was then elevated and the abdomen was entered without difficulty. At this point, we performed exploratory laparotomy. The liver was palpated and appeared normal. The gallbladder was normal. The pancreas was soft in the body and tail but firm in the head. There was no evidence of metastatic disease. Therefore, we proceeded with extending our incision to just below the umbilicus. Once the incision was opened widely, a Thompson retractor was brought on the operative field to facilitate with visualization. The falciform ligament was taken down and divided and ligated with 2-0 silk suture.

Extensive adhesions from the prior extended right colectomy were found. Numerous clips were noted through the planes between the colon, RUQ, and stomach. Loops of small bowel were adherent to the RUQ. Using careful dissection these adhesions were taken down. The ileo-colostomy was identified. A loop of small bowel was densely adherent to blind end of the transverse colon. Using 15 blade this was sharply taken down and a small less than 1 cm enterotomy was identified in the colon. This was closed with interrupted 3-0 silk. This adhesiolysis and enterotomy were required to help expose the pancreas and proceed with the operation. At this point, we proceeded with a Kocher maneuver. The head of the pancreas was completely mobilized. We palpated the head of the pancreas, which was firm. Intraoperative ultrasound was performed confirm location of the tumor in the head of pancreas. The metal biliary stent was also visible.

At this point, the gallbladder was taken down in a top down technique. The cystic duct was identified, encircled, divided and ligated with 2-0 silk suture. The cystic artery was identified, encircled, ligated with a 3-0 silk suture. The gallbladder was taken off the gallbladder bed. We did encounter oozing from the gallbladder fossa that was treated with electrocautery and Surgicel to establish hemostasis. Of note, the common bile duct was dilated and contained a metal stent.

At this point, we opened the gastrocolic ligament using the EnSeal device. The planes between the stomach and the pancreas were further developed. Adhesions were taken down. The middle colic vein was not present given the prior operation. The gastroepiploic vein was identified. The gastrocolic trunk was encircled and clamped and divided and doubly ligated. At this point, the inferior border of the pancreas was further defined. A tunnel was then made under the neck of the pancreas.

At this point, we turned our attention to the superior border of the pancreas and pylorus of the stomach. The hepatogastric ligament was taken down with electrocautery. The right gastric artery was identified, encircled and ligated with 2-0 silk suture. The pylorus was then palpated. Duodenal veins of Wilkie were taken down with an EnSeal device. The gastroepiploic artery and vein were encircled and ligated with 2-0 silk suture. At this point, the duodenum was divided with the GIA-75 blue load stapler approximately 2 cm from the pylorus. The stomach was then packed in the left upper quadrant out of the operative field.

At this point, we turned our attention to the common hepatic artery and the superior border of pancreas. Using careful dissection, we were able to identify the common hepatic artery lymph node (8A). This lymph node was then passed off the operative field. Underlying this, we were able to trace the common hepatic artery to the gastroduodenal artery. The gastroduodenal artery was identified, encircled and then test clamped with good flow into the left and right hepatic arteries. At this point, the GDA was triply ligated and divided. We then proceeded with identifying the portal vein. The tunnel under the neck of the pancreas was completed and an umbilical tape was then passed.

At this point, we then proceeded with dissecting out the bile duct. Using careful dissection we separated it from the portal vein. It was then encircled with a vessel loop and then divided with electrocautery. The distal margin of the bile duct was then divided and sent as a margin. This margin was reported as negative. The distal bile duct was then oversewn with 2-0 suture.

At this point, we turned our attention to below the transverse colon. The ligament of Treitz was identified. Soft tissue was dissected down with electrocautery fully mobilizing the ligament of Treitz. The small bowel was then traced approximately 20 cm. The jejunum mesentery was then opened with electrocautery. A GIA 75 blue load stapler was used to divide the jejunum. The mesentery of the proximal jejunum was taken with the EnSeal device along its mesenteric border. The jejunum was then passed under the mesenteric vessels to the right upper quadrant.

At this point, the superior and inferior borders of the neck of the pancreas were ligated with 3-0 silk sutures. The neck of the pancreas was divided with electrocautery. The pancreatic duct measured 4 mm.

At this point, we proceeded with dissecting the head of the pancreas off of the portal vein and SMA. To do this, small branching vessels of the portal vein were identified and ligated with 3-0 silk sutures and 4-0 and 5-0 Prolene. Then, the head of the pancreas was carefully dissected off the SMA with serial ligation with 2-0 and 3-0 silk sutures. The IPDA was identified separately, clamped and ligated.

At this point, I took the specimen to Pathology. Frozen section of the neck of the pancreas was then performed and the specimen was appropriately oriented. The frozen section indicated negative pancreatic margin. Low grade IPMN was noted.

At this point, we proceeded with reconstruction. The jejunum was passed in a retrocolic fashion to construction the pancreaticobiliary limb. This was passed through the native defect given prior extended right colectomy. The end was oversew with 3-0 silk suture. A pancreaticojejunostomy was created with a handsewn technique. This was duct to mucosa anastomosis with an inner layer of interrupted 5-0 Vicryl suture. Four sutures were placed. This was constructed over a 5-French pediatric feeding tube that was removed prior to completion of this anastomosis. The outer layer was constructed with interrupted 3-0 silk sutures. Approximately 10 cm distal to this anastomosis, we constructed a hepaticojejunostomy. The bile duct measured 12 mm. The anastomosis was performed with running 5-0 Vicryl.

At this point, an antecolic gastrojejunostomy was constructed approximately 40 cm downstream from the pancreaticojejunostomy. The antrum of the stomach was resected using two loads of the GIA 75 and passed off the operative field. The anastomosis was then created with GIA 75 blue load stapler. The common enterotomy was closed in two-layer anastomosis with an outer layer of 3-0 silk suture and inner layer of running 3-0 Vicryl suture. At this point, we inspected each anastomosis and they all appeared intact. A large clip was used to mark the pancreaticojejunostomy.

At this point, a 19 Blake drain was passed through the right upper quadrant incision and placed anterior to both anastomoses. It was secured to the skin with 2-0 nylon suture. We then proceeded with closure. Following protocol, we changed our gown and gloves and used a new sterile closing table. The midline was reapproximated with #1 looped PDS suture times two. Subcutaneous tissues were reapproximated with 3-0 Vicryl suture and the skin was reapproximated with 4-0 Monocryl suture. At this point, Dermabond was placed. The patient was then extubated and transferred to the PACU for further postoperative care.


Thank you
 
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haraml7

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Hello, After thoroughly reading this OP note i am looking at the 2nd paragraph. "prior extended right colectomy were found. The ileo-colostomy was identified. A loop of small bowel was densely adherent to blind end of the transverse colon. (IMPORTANT) Using 15 blade this was sharply taken down and a small less than 1 cm enterotomy was identified in the colon. This was closed with interrupted 3-0 silk. This adhesiolysis and enterotomy were required to help expose the pancreas and proceed with the operation." An Enterotomy is the surgical incision into an intestine. It may be purposeful or a complication of an abdominal surgery, such as exploratory laparotomies or hernia repair. An enterotomy can be done to remove an obstruction or foreign body from the intestine. I gather that this is where the surgeon made an incision in the colon, and he states that the enterotomy was required to help expose the pancreas and proceed with the operation. This can be used as the documentation is a denial comes in for this procedure. I would reference the last surgery just to get an idea of what the prior surgery exactly was to get more of an idea of why this procedure would have to be performed. Also, NCCI edits may come in handy to make sure the provider is getting reimbursed the appropriate amount for all of his work that he performed in this case. the patient also has a colostomy (44605)? Thank you for letting me help with this case. Very interesting.
 
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