Coding for General Surgery

moertle

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This is my 1st time to post anything so I hope that I did it correct. Thanks for any help you can give.
Can someone please help me code the below op notes. I am not real sure how many codes to use:


PREOPERATIVE DIAGNOSIS: Gastric carcinoma, status post chemoradiotherapy,familial polyposis syndrome with multiple colon polyps.

POSTOPERATIVE DIAGNOSIS: Gastric carcinoma, status post chemoradiotherapy,familial polyposis syndrome with multiple colon polyps.

PROCEDURES PERFORMED:

1. Subtotal gastrectomy with Roux-en-Y reconstruction.
2. Total proctocolectomy with Brooke ileostomy.
3. Feeding jejunostomy.
4. Liver resection en bloc with subtotal gastrectomy, wedge.



ANESTHESIA: General endotracheal.

COMPLICATIONS: None.

SPECIMEN TO PATHOLOGY: Stomach with attached portion lateral segment of the liver, a total proctocolectomy.

PREP: ChloraPrep and Betadine.

BRIEF HISTORY: The patient was treated with preoperative chemoradiotherapy, he was brought to the operating room at this time for gastrectomy, with Roux-en-Y reconstruction, and a total proctocolectomy with a Brooke ileostomy. It was felt that after his subtotal gastrectomy that an ileal loop pelvic pouch reconstruction would probably not be in his best interest. I should note that preoperative endoscopic ultrasound raised the question of involvement of the liver by his gastric tumor.

OPERATIVE SUMMARY: An epidural catheter was placed prior to induction of anesthesia. Adequate general endotracheal anesthesia was performed initiated, the patient was then prepped and draped in the usual sterile fashion in a dorsal lithotomy position. I should point out that an appropriate dose of cefoxitin was administered in the operating room within 1 hour of the incision and completed prior to the incision. It was redosed at an appropriate interval, and will not be continued postoperatively. SCDs were used for thromboembolic prophylaxis and will be continued postoperatively. Subcutaneous heparin will also be started. It will be started within 24 hours of procedure.

Initially, a small portion of the planned xiphoid to pubis incision was opened, mostly above the umbilicus, to assure there was no widely metastatic disease, such as carcinomatosis. An exploration was carried out, and while there was involvement of the primary tumor with the lateral side of the liver, there was no evidence of distant metastatic disease. Thus, the xiphoid pubis incision was opened down through skin and subcutaneous tissue, through the fascia, and entering the peritoneum care being taken to avoid injury to underlying viscera. An exploration was carried out revealing the gastric tumor, there was some India ink left from tattooing of the colon. The Bookwalter self-retaining retractor was placed. I should point out that after induction of the anesthesia before prepping the patient, the patient's anus was closed with a pursestring suture of 0 Prolene and a couple of sutures were used to suspend the scrotum up, these were removed after the case was finished.

Initially, the gastrocolic ligament was taken down with the ligature device leaving the gastroepiploics on the greater curvature of the stomach. This got us access to the lesser sac, and the duodenum was isolated, taking down most of this omentum with the LigaSure device. The pars flaccida was opened. The duodenum was divided approximately 2 cm distal to the pylorus with a single fire of a GIA-75 stapler with a blue load. The pars flaccida was taken down, and at this time additional division of the omentum, off the gastroepiploics was performed up to taking down all the inflow into the left gastroepiploics, but not to the short gastrics. The stomach was then divided, some of the insertion on the lesser curvature was preserved, and we divided this approximately 3 cm or so, possibly 4 above the palpable tumor in the stomach, apparently when it was out this shrunk. However, the stomach was divided with 2 fires of a GIA-75 stapler with green or gastric loads. This left the attachment only to the lateral segment of the liver on its posterior surface, not quite at the tip, but well away from the ligamentum teres. An area of liver approximately 6 or 7 cm in diameter was divided off of the remaining lateral segment, to be removed en bloc with the gastric carcinoma. Initially, sutures were placed at least 1 cm to 1.5 cm from the attachment of the tumor, basically mattress sutures of 2-0 silk, which were placed at each side of the liver edge. The liver was then basically scored with the argon beam coagulator, going through the substance. Small vessels were clipped, 1 large vein inferiorly and somewhat posteriorly was taken down with a single fire of an Endo-GIA 30 vascular stapler. Additional fires of the vascular stapler were applied over this area of liver division, the total distance was on the order of 8 cm or more. The argon beam coagulator and suture ligatures of 2-0 silk and 2-0 Vicryl were used, along with clips. Surgicel was placed. The coronary ligament was taken down to mobilize the lateral segment of the liver prior to division, after gastric division. The stomach and attached liver was then sent to pathology.

At this time, the lateral peritoneal attachments of the colon were taken down, bilaterally, and the mesoileum was mobilized from the ileum and the ileum divided just proximal to the ileocecal valve with a single firing of the GIA-75 stapler. The avascular spaces in the mesocolon were taken down with electrocautery, vessels were taken down, largely with the LigaSure device with the exception of the inferior mesenteric artery, after identifying both right and left ureters. The splenic flexure was very easy to take down and no misadventures occurred here, basically mobilized the colon from proximal to distal, and at this time started the rectal dissection. After dividing the inferior mesenteric vascular pedicle with the GIA-30 vascular stapler, the natural cleavage plane between the mesorectum and the pelvis was opened, starting posteriorly. Care was taken to do a total mesorectal incision in case any of these polyps that were in the rectum had cancer, although there was high grade dysplasia there was no overt cancer. Total mesorectal excision was performed, vessels were taken down with the LigaSure device. Lateral pedicles were mobilized. The anterior surface was developed, behind the seminal vesicles and prostate, after opening up the pelvic floor of peritoneum. The dissection was carried down to the pelvic floor circumferentially, hemostasis is excellent.

The dissection was carried down from the peritoneum at this point. A longitudinally based elliptical incision approximately 2 cm from the anal verge was performed, down through skin and subcutaneous tissue, and through the muscle with electrocautery. Working initially posteriorly, toward the coccygeal tip, I was able to join the dissection from up above, with hooking attachments and bringing them down, I was able to take these down with electrocautery and the LigaSure device. Ultimately all of the attachments were taken down, without any misadventure and the colon delivered out through the perineal wound. At this time, after a check for hemostasis, the pelvic floor was closed in 2 layers with a deep layer of muscle, with several interrupted sutures of 0 Vicryl, additional sutures of 0 Vicryl were placed for a second layer in the fat, subcutaneous tissue was then closed with several interrupted buried sutures of 2-0 Vicryl. The skin was closed with multiple interrupted simple and vertical mattress sutures of 3-0 nylon.

Attention was directed back to the abdomen. An appropriate area on the jejunum approximately 6-8 inches distal to the ligament of Treitz was chosen for jejunal division to create the Roux limb. A Roux limb of approximately 45 cm was then marked. The Roux was brought up to the gastric remnant, which was well-vascularized. An enterotomy was carried out on the anterior mesenteric surface approximately 8 cm or so distal to the jejunal tip, of the Roux limb, and the medial portion of the staple line was excised on the stomach. A single fire of a GIA-75 stapler was created to create the posterior suture line or back wall. There was an area of stomach between the anastomotic staple line and the division staple line, this was all inverted into the anastomosis. The common opening was then closed prior to oversewing the anterior staple line, with an inner inverting layer of 3-0 Vicryl in a simple running fashion, and an outer layer of 3-0 silk interrupted Lembert sutures. As mentioned, the staple line anteriorly was oversewn to imbricate the anastomotic staple line and the gastric division staple line. The jejunojejunostomy was constructed with a single fire of a GIA-75 stapler, excising some of the antimesenteric portion of the staple line of the proximal jejunum and creating an enterotomy in the Roux limb. The common channel was closed with 3-0 Vicryl in a simple running fashion, with an outer layer of multiple interrupted sutures of 3-0 silk placed in an interrupted Lembert fashion. An additional crotch stitch was placed on the other surface of the staple line.

A jejunostomy was then constructed, distal to the anastomosis, here the jejunal lumen was fairly small, thus it was felt that would be better to create a loop to itself, an enterotomy is made, a GIA-75 stapler was passed in each limb of the afferent and efferent jejunum, and fired. The common channel was closed with a TA 60 stapler. This created a large diameter, and we were able to place a pursestring suture of 2-0 silk, through which a multi-fenestrated 14-French red rubber Robinson catheter was passed into the distal jejunum, and a Wetzel tunnel was constructed over this with 3-0 Prolene in a simple running fashion, creating a long Wetzel tunnel of approximately 3 cm. A separate stab incision was carried out in the left lateral abdomen, this was after placing additional drains. A drain was placed down in the pelvis after covering the pelvic floor with a peritoneal flap utilizing 2-0 Vicryl in simple running fashion. The pelvis was drained with a separately placed fully fluted 19-French Blake drain through a separate stab incision in the left lower quadrant. In the right upper quadrant, another 19-French fully fluted Blake drain was placed, to drain both the gastric anastomosis and the duodenal stump. The separate stab incision in the left lateral abdomen was used to bring out the jejunostomy, this was attached to the abdominal wall, the exit site of the Witzel tunnel was tacked to the parietal peritoneum with a running parachute pursestring suture in the manner described by Eckhauser. An additional suture of 3-0 Vicryl further suspended the jejunostomy.

A 24 mm diameter button of skin was excised after precisely measuring it and drawing it in a circle, over the right anterior abdominal wall over the rectus abdominis in a place previously chosen by the enterostomal therapist. The skin button was excised, the subcutaneous tissue was mobilized off of the fascia, but not excised, and a cruciate incision was carried out in the anterior rectus sheath. A defect that would allow the ileostomy to come through was made that would allow 2 fingers only. The ileum was then brought through this, and tacked to the fascia with interrupted sutures of 3-0 silk. After a final check for hemostasis and assuring needle and sponge counts were correct, the Seprafilm was placed deep to the fascial incision and then the fascia was closed in 1 layer utilizing #1 Prolene in simple running fashion, care being taken to bury all knots. I should point out that the drains and jejunostomy had been tacked to the skin with nylon skin sutures. The skin at the midline incision was closed with staples. A sterile occlusive dressing was placed.

The staple line was excised from the Brooke ileostomy, and then a Brooke ileostomy constructed, with a nice protuberance, of at least 1.5 cm even after maturing the ileostomy, there were 4 corner sutures placed from the cut edge of the full-thickness of ileum, going down to the ileum at the level of the skin or slightly inferior to the dermis of the skin. Intervening areas were just closed dermis of skin to cut edge of ileum. A stoma appliance was placed. Sterile dressings were applied to the perineum, the patient was then extubated in the operating room and brought to the recovery room having tolerated his procedures well, without complications. It will be planned that he goes to the Intensive Care Unit.
 
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