landv
Contributor
Please help with coding this OP note. CPT 43848???? correct????? THANK YOU!!!
PREOPERATIVE DIAGNOSIS(es): Gastric outlet obstruction.
POSTOPERATIVE DIAGNOSIS(es): Gastric outlet obstruction.
OPERATION:
1. Exploratory laparotomy.
2. Lysis of adhesions and gastrogastrostomy.
ANESTHESIA: General.
SPECIMEN: None.
PROCEDURE: The patient was taken to the operating room and placed in the supine
position. The abdomen was prepped and draped in a sterile fashion. A generous
midline incision was made from the xiphoid to just above the umbilicus with
scalpel. Dissection was carried with electrocautery through the anterior
abdominal fascia and the peritoneum entered. Adhesiolysis was carried out.
There were adhesions of omentum to the anterior abdominal wall. The stomach was
adhesed to the liver. All these adhesions were taken down. The patient gave a
history of a gastric bypass and was thought that there was a gastrojejunal
anastomosis from her small gastric remnant pouch to the small bowel. With the
upper GI, no contrast passed beyond this pouch. Her anatomy was less than
straightforward.
I proceeded initially under the impression that she had a Roux-en-Y gastric
bypass; however, I was unable to identify any anastomosis from stomach to small
bowel. I mobilized the stomach anteriorly away from the adhesions of the liver
as well as the greater curve of the stomach. I then started from ligament of
Treitz distally to the ileocecal valve. There were extensive adhesions of small
bowel all of which were lysed and there was no small pyelo anastomosis carried
out. The small bowel was visualized in its entirety from ligament of Treitz
distal to the ileocecal valve and a small bowel was all intact without any
anastomosis or alteration of its native anatomy. At this point, I further
examined the stomach. There was a staple line visualized along the pouch. At
this point, I felt that the patient more than likely had a vertical banded
gastroplasty, although no mesh could be palpated. There were no other
anastomoses but a staple line of the stomach. All of the stomach remained in
place; however, there was clearly no communication from the small cephalad
pouch to the distal stomach or antrum. A nasogastric tube was placed per
Anesthesia and did not pass beyond this pouch.
At this point, I had several surgical options: One would be to switch one
bariatric surgery for another and proceed in converting her vertical band
gastroplasty to a Roux-en-Y gastric bypass; however, due to her age, her
malnutrition with albumin of 2.4, as well as the fact that I had not discussed
with her previously, I felt that this could be a highly morbid procedure, life
altering, with risks of dumping syndrome and the other problems associated with
gastric bypass that had not been extensively discussed with her preoperatively.
I did not feel that discussing this with her husband was appropriate as I did
not feel that he was able to make a decision for her as there were other
appropriate alternatives. I then thought that perhaps just a Roux-en-Y
gastrojejunostomy would alleviate her obstruction; however, as the stomach was
fairly mobile, I felt that sewing the pouch to the stomach distal to the staple
line in a gastrogastrostomy would bypass the obstruction, resume her native
anatomy with a low risk single anastomosis and is unlikely to lead to any
further sequela. I felt this was the safest option for this malnourished
patient who is 74 years old, and although it is possible that weight gain may
be an issue, she could have revision bariatric surgery in the future at some
point should she so desire; however, at this point, I believe relieving her
obstruction was what preoperatively I discussed with her and I felt that was a
safe and appropriate option. At this point after the stomach had been
mobilized, I did a handsewn anastomosis from pouch to the gastric remnant with
an outer layer of silk Lembert sutures and an inner layer of running Vicryl
sutures. The anastomosis was palpated to be patent. The nasogastric tube was
placed per Anesthesia into the antrum. Hemostasis being observed, the abdomen
was irrigated with clear return. Abdominal viscera were then placed back in
their native position. The abdominal fascia was closed with looped 0-PDS
suture, one from above, one from below and meeting and the middle and the skin
was closed with surgical staples. The patient tolerated the procedure well and
was transferred to the recovery area in satisfactory condition.
PREOPERATIVE DIAGNOSIS(es): Gastric outlet obstruction.
POSTOPERATIVE DIAGNOSIS(es): Gastric outlet obstruction.
OPERATION:
1. Exploratory laparotomy.
2. Lysis of adhesions and gastrogastrostomy.
ANESTHESIA: General.SPECIMEN: None.
PROCEDURE: The patient was taken to the operating room and placed in the supine
position. The abdomen was prepped and draped in a sterile fashion. A generous
midline incision was made from the xiphoid to just above the umbilicus with
scalpel. Dissection was carried with electrocautery through the anterior
abdominal fascia and the peritoneum entered. Adhesiolysis was carried out.
There were adhesions of omentum to the anterior abdominal wall. The stomach was
adhesed to the liver. All these adhesions were taken down. The patient gave a
history of a gastric bypass and was thought that there was a gastrojejunal
anastomosis from her small gastric remnant pouch to the small bowel. With the
upper GI, no contrast passed beyond this pouch. Her anatomy was less than
straightforward.
I proceeded initially under the impression that she had a Roux-en-Y gastric
bypass; however, I was unable to identify any anastomosis from stomach to small
bowel. I mobilized the stomach anteriorly away from the adhesions of the liver
as well as the greater curve of the stomach. I then started from ligament of
Treitz distally to the ileocecal valve. There were extensive adhesions of small
bowel all of which were lysed and there was no small pyelo anastomosis carried
out. The small bowel was visualized in its entirety from ligament of Treitz
distal to the ileocecal valve and a small bowel was all intact without any
anastomosis or alteration of its native anatomy. At this point, I further
examined the stomach. There was a staple line visualized along the pouch. At
this point, I felt that the patient more than likely had a vertical banded
gastroplasty, although no mesh could be palpated. There were no other
anastomoses but a staple line of the stomach. All of the stomach remained in
place; however, there was clearly no communication from the small cephalad
pouch to the distal stomach or antrum. A nasogastric tube was placed per
Anesthesia and did not pass beyond this pouch.
At this point, I had several surgical options: One would be to switch one
bariatric surgery for another and proceed in converting her vertical band
gastroplasty to a Roux-en-Y gastric bypass; however, due to her age, her
malnutrition with albumin of 2.4, as well as the fact that I had not discussed
with her previously, I felt that this could be a highly morbid procedure, life
altering, with risks of dumping syndrome and the other problems associated with
gastric bypass that had not been extensively discussed with her preoperatively.
I did not feel that discussing this with her husband was appropriate as I did
not feel that he was able to make a decision for her as there were other
appropriate alternatives. I then thought that perhaps just a Roux-en-Y
gastrojejunostomy would alleviate her obstruction; however, as the stomach was
fairly mobile, I felt that sewing the pouch to the stomach distal to the staple
line in a gastrogastrostomy would bypass the obstruction, resume her native
anatomy with a low risk single anastomosis and is unlikely to lead to any
further sequela. I felt this was the safest option for this malnourished
patient who is 74 years old, and although it is possible that weight gain may
be an issue, she could have revision bariatric surgery in the future at some
point should she so desire; however, at this point, I believe relieving her
obstruction was what preoperatively I discussed with her and I felt that was a
safe and appropriate option. At this point after the stomach had been
mobilized, I did a handsewn anastomosis from pouch to the gastric remnant with
an outer layer of silk Lembert sutures and an inner layer of running Vicryl
sutures. The anastomosis was palpated to be patent. The nasogastric tube was
placed per Anesthesia into the antrum. Hemostasis being observed, the abdomen
was irrigated with clear return. Abdominal viscera were then placed back in
their native position. The abdominal fascia was closed with looped 0-PDS
suture, one from above, one from below and meeting and the middle and the skin
was closed with surgical staples. The patient tolerated the procedure well and
was transferred to the recovery area in satisfactory condition.