Gastric Rouxen-Y converted to Gastric Sleeve


Dover, PA
Best answers
I have a provider who was scheduled to performe a Lap. Gastric Rouxen-Y, however, when he began the procedure he found that the intestines had adhesions all through out the colon area due to previous colon surgery. He steped out of the OR to discuss the case with the family who them opted for the Gastric Sleeve. He wants to bill for the Gastric Sleeve only, I feel that we need to bill for the Gastric Rouxe-Y with aborted procedure modifier 52 and then bill for the gastric sleeve. Can someone weight in on this case to let me know what their thoughts would be. I have the note below for your review.

1. Laparoscopic gastric sleeve procedure.
2. Laparoscopic lysis of adhesions.
3. Open repair of incisional hernia.

ANESTHESIA: General with endotracheal tube.

FINDINGS: This 48-year-old male had a long history of morbid obesity
resistant to treatment with very low-calorie diets. The patient had
undergone a prior open abdominal colectomy. At the time of surgery
he was found to have extensive adhesions arising from the omentum
and viscera to the anterior abdominal wall. He was also found to
have extensive adhesions from the small bowel to itself. After a
long period of lysing the adhesions measuring approximately 1 hour,
the ligament of Treitz could not be identified due to extensive
intra-loop adhesions from the small bowel to itself and to the
omental tissue. At that point I discussed with the family the option
of opening the patient and performing an open gastric bypass versus
a laparoscopic gastric sleeve procedure which would have the
advantage of not requiring any further manipulation of the small
intestine. The family opted for the gastric sleeve procedure. That
was done. Additionally the patient was found to have an incisional
hernia in the lower portion of this low midline incision from the
colectomy. A small incision was made overlying this hernia, and the
hernia was repaired in an open fashion.

PROCEDURE: The patient was brought to the operating room, placed in a
supine position, and general anesthesia was induced through an
endotracheal tube. The anterior abdomen was prepped and draped in a
sterile fashion. Using a scalpel, a 5 mm incision was made in the
left subcostal area midclavicular line. Through this incision a
Veress needle was placed, and the abdomen was insufflated with CO2
gas. A 5 mm trocar was placed through this area. The laparoscope was
placed through the trocar. The abdomen was surveyed for trocar
injuries. None were appreciated. A second 5 mm trocar was then
inserted under laparoscopic control. The adhesions from the
intra-abdominal viscera to the anterior abdominal wall were then
tediously and carefully dissected free from the anterior abdominal
wall. After approximately 1 hour of dissection, all the adhesions
from the intra-abdominal viscera to the anterior abdominal wall had
been taken down. At that point additional trocars were placed, and
an attempt was made to locate the ligament of Treitz. Due to
extensive adhesions from the small bowel to itself, this area could
not be easily located. At this point I left the room and went out
and discussed the situation with the family. They elected a
laparoscopic gastric sleeve. I re-entered the room and we proceeded
along that avenue. The attachments of the stomach to the colon were
taken down using the LigaSure device. The entire greater curvature
was thus mobilized up to the area of the phrenoesophageal ligament.
The stomach was rotated upward, and adhesions to the posterior
stomach were also taken down until the stomach simply rested on the
lesser curvature. A #38 bougie was then placed into the stomach.
Beginning at an area approximately 6 cm from the pylorus, stapling
was done to remove most of the greater curvature of the stomach
pushing the stapler up against the #38 bougie. This was done
repeatedly using Duet stapling cartridges until two-thirds of the
stomach was excised, again up to the angle of crus. The staple line
was then observed and appeared to be intact. An endoscopy was
performed. The duodenum was clamped just distal to the pylorus, and
the gastric sleeve was insufflated while the staple line was under
saline. No leakage was noted and the scope passed easily through the
gastric tube. The clamp was removed and the endoscope was removed.
The patient had been found to have a small incisional hernia in the
lower portion of his low midline incision. The hernia had been
incarcerated with omental tissue. This had all been taken down as
part of the lysis of adhesions. A 3 cm incision was made above this
hernia. The incision was carried downward through the skin and
subcutaneous tissues until the hernia sac was encountered. The
gastric remnant was collected in an EndoCatch tube. An opening was
made through the hernia and the string of the EndoCatch bag was
pulled through the hernia. The stomach was thus delivered through
this area. It was sent to pathology for examination. The hernia
defect, which also then measured approximately 3 cm, was closed
using a running suture of #1 looped PDS Plus. Once this was closed,
the abdomen was re-insufflated, and 2 additional sutures were placed
of #0 Polysorb using the suture passer across this area. The 15 mm
trocar sites were then closed using the suture passer and #0
Polysorb. The subcutaneous tissues of the hernia repair site were
closed using a running suture of 2-0 Polysorb. All skin was closed
using a combination of 4-0 Biosyn and octylseal glue. The patient
tolerated the procedure well and left the operating room in
satisfactory condition.

POSTOPERATIVE DIAGNOSIS: Morbid obesity, hypertension, obstructive
sleep apnea, hyperlipidemia, chronic back pain, arthritis, prior
history of a colectomy, extensive intra-abdominal adhesions, and
incisional hernia.



Best answers
I would bill for the lap gastric sleeve and the open rpr incarcerated hernia @ sep incisional site. You could try the -22 on the sleeve, but one hour of lysis is pretty borderline for that. I would not bill the lap roux-y, as he never began actually constructing the roux.