Wiki Diagnostic laparoscopy with conversion to exploratory laparotomy and control of bleeding

[sdunaway1]

Will you pls review this case? We are thinking that we could possibly use this code.

35840 for exploration of post op hemorrhage, thrombosis, or infections, abdomen.



Following a previously performed surgical procedure, the operative wound is re-opened and the surgical site explored for post-operative hemorrhage, thrombosis, or infection. A patient with symptoms indicative of a post-operative hemorrhage, such as low red blood count; thrombosis, such as pain, redness, swelling, and/or shortness of breath; or infection, such as fever, redness, swelling, and/or tenderness over the surgical site is evaluated. If non-surgical measures fail to resolve the symptoms, the patient is returned to the operating room for exploration of the surgical site. The surgical incision is re-opened and thoroughly inspected. Any bleeding is controlled by ligation or cautery. Any blood clots are evacuated. Any evidence of infection is treated by opening abscess pockets and draining pus and fluid. The surgical wound is flushed with normal saline or antibiotic solution. Drains are placed as needed. The surgical wound may be closed or packed with gauze.



The only thing is that the bleeding is controlled with hemoclips and floseal and surgical not ligation and cautery. So maybe we would have to use an unlisted code and maybe use this for a ‘like’ code?



And then add the transfusion code - looks like it could be used with a modifier.

please help !!! thank you!

 

[Cmama12]

Definitely need more details - without the note, hard to say but this is a code in the Cardiovascular section - Codify states
Tips
Code 35820 differs from other excision or repair codes because it takes place in the circulatory system. This means the provider’s concern is with managing a hemorrhage via the blood vessels, rather than by exploring the source of the bleeding.

49000 is exploratory laparotomy

 

[sdunaway1]

Im so sorry - here is the operative report- thank you so much for reviewing this report

Preoperative Diagnosis:
Hemodynamic instability secondary to intra-abdominal bleeding after cholecystectomy

Postoperative Diagnosis:
Hemodynamic instability secondary to intra-abdominal bleeding after cholecystectomy

Procedure:
Diagnostic laparoscopy with conversion to exploratory laparotomy and control of bleeding

77 year old male who underwent laparoscopic cholecystectomy in Lewiston yesterday morning. He represented after discharge and was found to be profoundly hypotensive and was transferred to Kootenai health to the intensive care unit. Imaging suggested hemoperitoneum and with his profound anemia and those findings we are proceeding urgently to the operating room. Please see history and physical for more details.

Findings:
Approximately 4 L of blood in the abdomen and an additional liter of clot was evacuated. Bleeding site identified to be a small artery likely off of the right hepatic artery but difficult to determine exact origin. Controlled with clips, Surgiflo, and Surgicel. Patient received 5 units packed red blood cells, 3 units FFP, and 1 unit platelets.

Description of procedure:
The risks and benefits of the procedure were explained to the patient and informed consent was obtained. The patient was taken to the operating room, placed in the supine position, and after induction of anesthesia was draped and prepped in the sterile fashion. A timeout was performed, perioperative antibiotics administered, and bilateral SCDs placed.

A supraumbilical 5 mm skin incision was made and entrance into the intraperitoneal cavity was made under direct visualization with a direct entry trocar. The abdomen was insufflated to 15 mmHg pressure. We immediately encountered a significant amount of clot and dark blood throughout the abdomen. A subxiphoid 10 mm incision was made and a 10 port was placed and we began suctioning. At this point anesthesia informed us that the patient's blood pressure was in the 40s systolic and so we converted to a laparotomy. Ports were removed and a midline laparotomy incision was made with a 10 blade. The abdomen was opened and all 4 quadrants packed. This allowed us time to transfuse and packed red blood cells to bring his pressure up which worked well. At this point I did attempt a left subclavian Cordis for assistance with resuscitation and easily accessed the left subclavian vein on multiple trials but was unable to pass the guidewire due to likely stenosis. I was then informed that attempts at bilateral internal jugular central lines made earlier by the critical care attending were also unsuccessful for the same reason. With this knowledge, I then stopped attempting central access and we utilized the patient's femoral line for further transfusion.

Once his hemodynamics improved we began by removing the packing beginning in the lower quadrants where there was no evidence of ongoing bleeding. We then remove the packs in the left upper quadrant and there is no bleeding around the spleen. In all we evacuated approximately 4 L of blood and additional liter of clot. We then turned our attention to the right upper quadrant and removed the packs and identified some clot in the gallbladder fossa. There is no obvious ongoing bleeding. I then removed the clot and was able to identify the source of bleeding which was a small artery in the gallbladder fossa. It is unclear whether this represented the cystic artery but it did appear to be a little higher and likely coming off the right hepatic artery. I did visualize the other clips from the previous surgery in the area of the cystic duct and cystic artery and those were quite a bit lower so I believe this was likely of the hepatic artery. I was able to control this with hemoclips followed by Floseal and Surgicel. The abdomen was thoroughly irrigated and suctioned and all the clots evacuated. We ran the bowel in its entirety, inspected the omentum, and visualized the retroperitoneum and there was no evidence of any other etiology of bleeding. The fascia was closed with a #1 looped PDS suture and skin incision was closed with staples. The patient was taken to the intensive care unit still intubated and in critical but stabilizing condition.

EBL:
No significant blood loss from the procedure but 4 L of blood and 1 L of clot evacuated from the abdomen

Complications:
None

Drains:
None

Specimens:
None