lcathey@smsc.org
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Need help with this one. Dr. used cpt 49002 and 47900, but i'm not sure this is correct and the hospital cross code is 51.71 which crosses over to 49999. She is also in post op for lapchole, and distal gastrectomy/loop gastrojejunostomy by a different surgeon. I would appreciate any suggestions:
PREOPERATIVE DIAGNOSIS:
Abdominal pain.
POSTOPERATIVE DIAGNOSES:
1. Abdominal pain.
2. Bile peritonitis, secondary to biliary tract leak.
PROCEDURES PERFORMED:
1. Central line placement.
2. Exploratory laparotomy with control of biliary leak and washing out of the abdomen.
SPECIMEN:
None.
FINDINGS:
The patient was found to have bile in her abdomen immediately upon attempt to place a Hasson trocar for her laparoscopy, so no laparoscopy was done and she was converted to a laparotomy. She had about 15 to 1800 mL of bile in her abdomen with multiple areas of bile exudate on loops of bowel. Her anastomosis at the gastrojejunostomy appeared intact without leakage. There was no abscess. It appeared that her leak was coming at the base of her cystic duct. This was oversewn with control of the leak and a cholangiogram was done, as described below, that showed no extravasation.
DESCRIPTION OF PROCEDURE:
Upon induction of adequate anesthesia, the patient already had an NG tube and a Foley catheter. SCDs had been in already been in place and Lovenox had already been injected. I prepped and draped the left chest and, in the usual fashion, accessed the left subclavian vein and placed a triple lumen central line. I had good venous return. It was secured and dressed.
At this point, we then prepped and draped her abdomen. I used a Hibiclens wash, followed by alcohol, followed by a clear sticky drape. I made a small incision just above her umbilicus and, in the open fashion, went to place a Hasson trocar, but upon entering the peritoneal cavity, a significant amount of bile came out. At this point, I knew that we had a bile leak to go after and did not feel that laparoscopy was the appropriate choice. I made an upper midline incision and, in fact, went from the sternum to the midpoint beneath her umbilicus and immediately aspirated out approximately 15 to 1800 mL of bile.
The first thing I did was check her gastrojejunostomy. That anastomosis was intact without any evidence of leakage. I ran her small bowel and found no other problems. I went ahead and then lifted up the liver and began some blunt dissection down to where her cystic duct stump was. I could not get to the duodenal stump as it was encased in some inflammatory tissue and I did not want to dissect down, if I did not have to, to that. When we spent time looking at her cystic duct stump area, we finally found a small leak at the base of her cystic duct stump. I took the clip off that had been previously placed, and I oversewed this stump with a couple of 4-0 figure-of-eight Vicryl sutures. We then irrigated that subhepatic space well and found no further biliary leak.
At this point, I took a 25-gauge butterfly needle and after several attempts was able to access the common hepatic duct. I then injected contrast and, under fluoroscopy, could see that the bile flowed briskly into her duodenum with no duodenal stump leak, no extravasation out of the oversewn areas, and no other pathology, particularly no cramping of her common bile duct from my oversewing. With this completed, we irrigated that area well and then began a systematic 4-quadrant irrigation of the abdomen, peeling off inflammatory exudate off multiple areas of small bowel. With this completed and no other pathology noted, I placed a Blake drain underneath her subhepatic space on the right, covering that bile leak repair. Then I placed another Blake drain in the left upper quadrant up underneath the left hemidiaphragm. These were secured at the skin level with silk.
Then I went ahead and closed the fascia with interrupted #1 Vicryl Plus sutures with interspersed #1 Prolene sutures and then infiltrated the wound with Marcaine, irrigated it out well. With no bleeding noted, I then closed the subcutaneous layer with interrupted 3-0 Monocryl sutures and the skin with staples and a dressing. The drains were dressed. The central line site was dressed, and the patient was transported to the intensive care unit intubated but in stable condition. Final needle and sponge counts were correct.
PREOPERATIVE DIAGNOSIS:
Abdominal pain.
POSTOPERATIVE DIAGNOSES:
1. Abdominal pain.
2. Bile peritonitis, secondary to biliary tract leak.
PROCEDURES PERFORMED:
1. Central line placement.
2. Exploratory laparotomy with control of biliary leak and washing out of the abdomen.
SPECIMEN:
None.
FINDINGS:
The patient was found to have bile in her abdomen immediately upon attempt to place a Hasson trocar for her laparoscopy, so no laparoscopy was done and she was converted to a laparotomy. She had about 15 to 1800 mL of bile in her abdomen with multiple areas of bile exudate on loops of bowel. Her anastomosis at the gastrojejunostomy appeared intact without leakage. There was no abscess. It appeared that her leak was coming at the base of her cystic duct. This was oversewn with control of the leak and a cholangiogram was done, as described below, that showed no extravasation.
DESCRIPTION OF PROCEDURE:
Upon induction of adequate anesthesia, the patient already had an NG tube and a Foley catheter. SCDs had been in already been in place and Lovenox had already been injected. I prepped and draped the left chest and, in the usual fashion, accessed the left subclavian vein and placed a triple lumen central line. I had good venous return. It was secured and dressed.
At this point, we then prepped and draped her abdomen. I used a Hibiclens wash, followed by alcohol, followed by a clear sticky drape. I made a small incision just above her umbilicus and, in the open fashion, went to place a Hasson trocar, but upon entering the peritoneal cavity, a significant amount of bile came out. At this point, I knew that we had a bile leak to go after and did not feel that laparoscopy was the appropriate choice. I made an upper midline incision and, in fact, went from the sternum to the midpoint beneath her umbilicus and immediately aspirated out approximately 15 to 1800 mL of bile.
The first thing I did was check her gastrojejunostomy. That anastomosis was intact without any evidence of leakage. I ran her small bowel and found no other problems. I went ahead and then lifted up the liver and began some blunt dissection down to where her cystic duct stump was. I could not get to the duodenal stump as it was encased in some inflammatory tissue and I did not want to dissect down, if I did not have to, to that. When we spent time looking at her cystic duct stump area, we finally found a small leak at the base of her cystic duct stump. I took the clip off that had been previously placed, and I oversewed this stump with a couple of 4-0 figure-of-eight Vicryl sutures. We then irrigated that subhepatic space well and found no further biliary leak.
At this point, I took a 25-gauge butterfly needle and after several attempts was able to access the common hepatic duct. I then injected contrast and, under fluoroscopy, could see that the bile flowed briskly into her duodenum with no duodenal stump leak, no extravasation out of the oversewn areas, and no other pathology, particularly no cramping of her common bile duct from my oversewing. With this completed, we irrigated that area well and then began a systematic 4-quadrant irrigation of the abdomen, peeling off inflammatory exudate off multiple areas of small bowel. With this completed and no other pathology noted, I placed a Blake drain underneath her subhepatic space on the right, covering that bile leak repair. Then I placed another Blake drain in the left upper quadrant up underneath the left hemidiaphragm. These were secured at the skin level with silk.
Then I went ahead and closed the fascia with interrupted #1 Vicryl Plus sutures with interspersed #1 Prolene sutures and then infiltrated the wound with Marcaine, irrigated it out well. With no bleeding noted, I then closed the subcutaneous layer with interrupted 3-0 Monocryl sutures and the skin with staples and a dressing. The drains were dressed. The central line site was dressed, and the patient was transported to the intensive care unit intubated but in stable condition. Final needle and sponge counts were correct.