mieka.schambach
Contributor
We coded the below as 15734 but the insurance is stating it's not supported by the op note. What else should we try?
| Operative Report Start date: 11/13/24 Start time: 0830 Pre-procedure diagnosis: 1. Incisional hernia - recurrent, incarcerated - greater than 10 cm size 2. Abdominal wall separation Post-procedure diagnosis: same as pre-procedure dx, 3. Intraperitoneal adhesions Procedures performed: 1. Robotic incisional hernia repair with bilateral posterior component separation 2. Robotic bilateral TAR procedure 3. Robotic lysis of adhesions (separate procedure) Technique/Procedure: The patient was brought to the operating suite and placed under general anesthesia. the patient did receive appropriate preoperative antibiotics, had SCDs placed for DVT prophylaxis, and then had the abdomen prepped and draped in the normal sterile fashion. Local anesthetic of 0.5 percent Marcaine plain was injected at the incision sites prior to incision and at the end of the procedure. Initially there was approximately 12 millimeter transverse incision made in the left subcostal region. A 5 mm Optiview trocar was then inserted into the peritoneal cavity under direct visualization. The abdomen was insufflated in the above findings were noted. Two additional trocars were then placed in the left abdomen with an 8 millimeter placed in the lateral left subcostal region and another 8 millimeter placed in the left flank region. The 5 mm trocar was then upsized to a 12 mm trocar in the left subcostal position. The patient was then positioned appropriately and the robotic da Vinci patient cart was brought up to the operative field and docked to the trocars. Initially all of the adhesions of the omentum to the anterior abdominal wall were taken down using hook cautery. Then the omentum was reduced out of the hernia sacs in all locations using hook cautery. This extensive lysis of adhesions took a good portion of the beginning of the case, and therefore was a separately identifiable and billable procedure in the case. Eventually the anterior abdominal wall was cleared and the transversus abdominis release procedure began initially on the patient's right side. First the posterior rectus sheath was separated away from the rectus muscle starting a few millimeters from the medial edge of the muscle. This was divided all the way from the subxiphoid region down to the lower rectus muscle past the arcuate line. The rectus sheath was peeled away from the rectus muscle all way to the lateral edge of the rectus muscle along the entire length until the perforating neurovascular bundle was encountered. At that location the transversus abdominis muscle was divided or its appropriate aponeurosis starting from the subxiphoid region going all way down to the lower abdomen. The then the peritoneum was separated away from the transversus abdominus muscle going out laterally all way to the visceral edge. This completed the release procedure on the patient's right side. This concluded the robotic portion on the patient's left side. Three 8 millimeter trocars were then inserted along the patient's right side under direct visualization placing 1 in the right upper quadrant, 1 in the right flank , and another 1 in the right lower quadrant. The robot was then rotated 180 degrees and docked to these trocars. A similar transversus abdominis release procedure was then performed on the patient's left side creating the posterior component separation all way to the visceral edge on this side as well. Once this flap was created the posterior rectus sheath was reapproximated in the midline using a 2 0 V lock suture in a running stitch. Any additional defects in the posterior rectus sheath or peritoneal area were closed using 2-0 V lock suture in interrupted figure-of-eight stitches. Then the rectus muscles were reapproximated and repaired in the anterior abdominal wall using an #1 V lock suture in a running stitch. There were several sutures needed total to span the entire length. During this process, the hernia defects were all primarily closed with the same #1 V lock suture. At this point the defect was measured using a ruler and a mesh was brought onto the field and cut to size. An approximately 10 x 25 cm strip was inserted into the peritoneal cavity. It was initially sewn in place using an 0 silk suture in several interrupted stitches circumferentially. Then an 0 V lock absorbable suture was used to secure the periphery of the mesh to the anterior abdominal wall circumferentially. This concluded the bilateral transversus abdominis release procedure as well as the incisional hernia repair. This concluded the robotic portion of the case in the da Vinci patient cart was undocked from the trocars and removed from the operative field. The left upper quadrant subcostal 12 millimeter incision site was closed with a fascial closure device and an 0 Vicryl suture. The other trocars were all removed under direct visualization and the abdomen was desufflated. All the skin incisions were closed using a 4 0 Monocryl suture in interrupted subcuticular stitches. They were then cleaned and dressed normal fashion Steri-Strips were placed on top. Patient was recovered from anesthesia without any problems and moved to the recovery room stable condition. Primary Surgeon: Vineet Choudhry, MD Assistant(s): none Anesthesia: general anesthesia, local anesthesia Operative findings: 1. Patient was found to have significant adhesions of the omentum to the anterior abdominal wall along the midline. The lateral sides of the abdomen were relatively spared of adhesions. However the omental adhesions to the midline were relatively dense and extensive. There was a large amount of time required to lyse these adhesions and reduced the omentum from all the different hernia defects. Part of this was also due to the large number of defects that he had. This was a separately billable and identifiable procedure due to the extensiveness of it and length of time required to perform it. 2. The patient was found to have numerous midline hernias. These were hard to number total but perhaps he had 10-15 different defects. Most of these were relatively small about 1-2 cm in size. However he had more dominant ones located in the periumbilical region which were 2-3 cm in size each. There was also another more dominant 1 in the lower midline which was where the recent bowel got incarcerated creating a small-bowel obstruction. There was no bowel incarcerated within it at the beginning of the case currently. There was omentum incarcerated within all these defects. There was no evidence of any tissue strangulation. There was again no evidence of any bowel involvement or obstruction. The length of all the defects from top to bottom was measured at approximately 18 cm in length making the hernia greater than 10 cm in size. This was a recurrent hernia in the periumbilical region. 3. The patient also had a concurrent abdominal wall separation. This was measured at approximately 6-8 cm in diameter at its widest in the periumbilical region where the dominant defects were. All the hernia defects were located within this abdominal wall separation. Was felt that without repair of this that the patient would be at higher risk of recurrent herniation along the midline as well as new herniations in the future. Therefore it was repaired primarily as well during the case. This ultimately is what was repaired by doing the bilateral posterior component separation TAR procedure. 4. No other significant acute or chronic findings were noted throughout the abdomen on exploration. Other than the omental adhesions in the midline there was no other significant bowel adhesions identified, especially any interloop adhesions. Specifically the LUQ was clear of any adhesions. Complications: none Estimated blood loss in ml's: 25 Estimated blood loss: expected Specimens removed/altered: none Cultures sent: No Drain(s)/tube(s): none Implant(s): Ethicon Prolene Mesh - Cut to 10x25 cm size with rounded edges Disposition: plan to D/C home Counts: Sponge count: correct Instrument count: correct Needle count: correct Cottonoid count: correct Wound class: clean Dictation number: None |