Diagnostic laparoscopy and enterectomy roux limb

TBarnes35

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Hendersonville, TN
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Hello Everyone,

I coded 44202 but want to code 43644 due to roux limb as well. Please advise. Thanks.
Operative Report

PREOPERATIVE DIAGNOSIS
Small-bowel obstruction.

POSTOPERATIVE DIAGNOSIS
Small-bowel cholecystitis.

PROCEDURES
1. Diagnostic laparoscopy.
2. Excision of most proximal portion Roux limb (enterectomy).

ANESTHESIA
General.

ESTIMATED BLOOD LOSS
25 mL

PROCEDURAL SUMMARY
With the patient in the supine position after the abdomen was prepped with ChloraPrep and draped and under a general anesthetic, a 5 mm incision was made in the right midclavicular line at the level of the anterior-superior iliac crest. A Veress needle was passed through this incision and through the anterior abdominal wall and the drop test verified the intraabdominal position of the needle. The abdomen was then insufflated with CO2. After sufficient insufflation, the Veress needle was removed and a 5 mm trocar passed through this same incision. The laparoscope verified the intraabdominal position of the trocar. Another 5 mm trocar was placed in the left midclavicular line at the same level and a 10 mm trocar placed at the level of the umbilicus in the right anterior axillary line. Attention was first turned to the upper abdomen at the configuration of the previous gastric bypass. The Roux limb was identified. It was adherent to the anterior abdominal wall and these adhesions were taken down. Next, the Roux limb was followed to the jejunojejunostomy, which appeared normal. The afferent limb was followed to the ligament of Treitz and it did not appear to be distended. The pylorus and antrum were examined and appeared normal. The gastric remnant was seen and not distended. Next, the efferent limb was followed all the way to the ileocecal valve. There were no adhesions. There was no obstruction. There was a short segment in the mid jejunum where the small bowel appeared slightly distended but again there were no adhesions or internal herniation. Next, the Roux limb was examined carefully. It appeared normal and it was followed all the way to where it was adherent to the inferior surface of the left lobe of the liver. These adhesions were not taken down. The most proximal portion of the Roux limb superior to the level of the anastomosis was about 5 cm in length. It appeared somewhat redundant. Because the patient has chronic stomal ulcers and since the possibility of stasis in the Roux limb was entertained, this redundant portion of the Roux limb was excised. This was accomplished by first dividing the mesentery, then dividing the small bowel with an Echelon powered GIA stapler (blue tissue load). A Blake drain was laid in the left upper quadrant to exit through the left lower quadrant incision. Hemostasis was ensured and the trocars were removed as the abdomen was deflated. Each of the trocar incisions were closed with a 4-0 Monocryl in a subcuticular layer and Dermabond was used to approximate the epidermis. The Blake drain was sutured into place with a 2-0 nylon suture. There was a 25 mL blood loss. There were no intraoperative complications. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
 
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