AmandaM.318414
Guest
I am really having trouble choosing an appropriate CPT code for this surgery. I appreciate any assistance or ideas.
POSTOPERATIVE DIAGNOSIS:
Pancreatic cystic neoplasm.
NAME OF OPERATION:
1. Middle pancreatectomy.
2. Roux-en-Y pancreaticojejunostomy.
DESCRIPTION OF PROCEDURE:
We entered the abdomen via an upper midline incision. The peritoneum was entered sharply. There was no evidence of metastatic disease. The Bookwalter retractor was placed. We first entered the lesser sac through the gastrocolic omentum. The anterior and inferior borders of the pancreas were cleaned. The transverse mesocolon was dissected free. We were able to identify the infrapancreatic superior mesenteric vein. This was traced up to the pancreas, and a tunnel was begun to be created. We then dissected the superior border of the pancreas. We found a portal vein above the pancreas. A complete tunnel beneath the neck of the pancreas and above the vein was made. The cyst was located in the neck of the pancreas, and this was the region that was anticipated to be removed. We dissected the stomach and duodenum off the anterior surface of the pancreas to the level of the gastroduodenal artery. We were able to see on the CT scan that the cyst was located to the left of the gastroduodenal artery and that if the pancreas were transected here, it would be encompassed by the resection specimen. Therefore, a GIA stapler (purple load, 60 mm, SeamGuard) was placed beneath the neck of the pancreas in this region of anticipated transection. The pancreas was then transected with the stapler in 1 fire. We then dissected the pancreas in a right to left direction off the portosplenic confluence. An approximate 4-5 cm length of pancreas was freed for resection. We came through the pancreas on the left using Bovie electrocautery. Meticulous hemostasis was confirmed and achieved. The specimen was sent for frozen section analysis of both the proximal and distal margins and to confirm the presence of the cyst.
We did later hear from the pathologist that the margins were clear and that the cyst was present and close to the right-sided margin, but free from it. We then began our reconstruction. A point on the proximal jejunum was selected. A window in the mesentery was made. The jejunum was transected using a GIA stapler (blue load, 80 mm). The distal limb was then brought through the transverse mesocolon in a retrocolic fashion. An end-to-side pancreaticojejunostomy was then created in a standard fashion using an outer layer of interrupted 3-0 silk suture and an inner layer of running 3-0 PDS suture. The pancreas was soft and friable. The pancreatic duct was not dilated, but it was identified. It was incorporated into the inner suture line. The bowel was then imbricated over the anastomosis. It appeared to be watertight. The Roux limb was then secured to the transverse mesocolon using 3-0 silk suture. Approximately 40 cm downstream of the pancreaticojejunostomy, a point on the jejunum was selected. An end-to-side jejunojejunostomy was then created in a standard fashion using an outer layer of interrupted 3-0 silk suture and an inner layer of running 3-0 PDS suture. The bowel was imbricated over the anastomosis. The anastomosis was checked for patency. The abdomen was once again copiously irrigated, and meticulous hemostasis was confirmed. A #19 round Blake drain was then brought out through the anterior abdominal wall via separate stab incision in the left mid abdomen. It was positioned adjacent to the cut edge of the pancreas as well as the anastomosis. It was secured in place using a 2-0 nylon suture. The fascia was then closed using a running #1 looped PDS suture. The wound was irrigated. The skin was closed using staples.
Thank you very much-
POSTOPERATIVE DIAGNOSIS:
Pancreatic cystic neoplasm.
NAME OF OPERATION:
1. Middle pancreatectomy.
2. Roux-en-Y pancreaticojejunostomy.
DESCRIPTION OF PROCEDURE:
We entered the abdomen via an upper midline incision. The peritoneum was entered sharply. There was no evidence of metastatic disease. The Bookwalter retractor was placed. We first entered the lesser sac through the gastrocolic omentum. The anterior and inferior borders of the pancreas were cleaned. The transverse mesocolon was dissected free. We were able to identify the infrapancreatic superior mesenteric vein. This was traced up to the pancreas, and a tunnel was begun to be created. We then dissected the superior border of the pancreas. We found a portal vein above the pancreas. A complete tunnel beneath the neck of the pancreas and above the vein was made. The cyst was located in the neck of the pancreas, and this was the region that was anticipated to be removed. We dissected the stomach and duodenum off the anterior surface of the pancreas to the level of the gastroduodenal artery. We were able to see on the CT scan that the cyst was located to the left of the gastroduodenal artery and that if the pancreas were transected here, it would be encompassed by the resection specimen. Therefore, a GIA stapler (purple load, 60 mm, SeamGuard) was placed beneath the neck of the pancreas in this region of anticipated transection. The pancreas was then transected with the stapler in 1 fire. We then dissected the pancreas in a right to left direction off the portosplenic confluence. An approximate 4-5 cm length of pancreas was freed for resection. We came through the pancreas on the left using Bovie electrocautery. Meticulous hemostasis was confirmed and achieved. The specimen was sent for frozen section analysis of both the proximal and distal margins and to confirm the presence of the cyst.
We did later hear from the pathologist that the margins were clear and that the cyst was present and close to the right-sided margin, but free from it. We then began our reconstruction. A point on the proximal jejunum was selected. A window in the mesentery was made. The jejunum was transected using a GIA stapler (blue load, 80 mm). The distal limb was then brought through the transverse mesocolon in a retrocolic fashion. An end-to-side pancreaticojejunostomy was then created in a standard fashion using an outer layer of interrupted 3-0 silk suture and an inner layer of running 3-0 PDS suture. The pancreas was soft and friable. The pancreatic duct was not dilated, but it was identified. It was incorporated into the inner suture line. The bowel was then imbricated over the anastomosis. It appeared to be watertight. The Roux limb was then secured to the transverse mesocolon using 3-0 silk suture. Approximately 40 cm downstream of the pancreaticojejunostomy, a point on the jejunum was selected. An end-to-side jejunojejunostomy was then created in a standard fashion using an outer layer of interrupted 3-0 silk suture and an inner layer of running 3-0 PDS suture. The bowel was imbricated over the anastomosis. The anastomosis was checked for patency. The abdomen was once again copiously irrigated, and meticulous hemostasis was confirmed. A #19 round Blake drain was then brought out through the anterior abdominal wall via separate stab incision in the left mid abdomen. It was positioned adjacent to the cut edge of the pancreas as well as the anastomosis. It was secured in place using a 2-0 nylon suture. The fascia was then closed using a running #1 looped PDS suture. The wound was irrigated. The skin was closed using staples.
Thank you very much-