philnamba
Contributor
I was always told to code a hiatal hernia as a ventral because they "are the same" but I think this op note leans more towards a paraesphageal code. Can anyone help? How would you code the following operative report?
"Under adequate general anesthetic, the abdomen was prepped and draped in the usual sterile fashion. 25% bupivacaine with epinephrine was injected throughout for postop pain control. A left lower abdominal 5 mm optic view trocar was placed under direct vision and the abdomen insufflated with CO2 to pressure 15 cm of water. A subxiphoid Nathanson liver retractor was placed under direct vision and used to elevate the left lobe of the liver. Gross expiration the abdomen revealed no obvious pathology or injury. A hiatus was inspected and did appear to have a moderate-sized hiatal hernia with gastric sleeve herniated into the mediastinum. A left-sided 5 mm port and right-sided 5 and 10 mm port replaced under direct vision as well. The harmonic scalpel was used to dissect the hiatus circumferentially. The crura were identified posteriorly and the moderately enlarged hiatus dissected circumferentially as well. The hernia sac and phrenoesophageal ligament were divided, taking care to identify preserved vagus nerves. Dissection was carried up into the mediastinum and esophagus for several centimeters, allowing persistent reduction of the hernia. A 36 and then a 56 French bougie were placed into the esophagus for sizing purposes. A posterior suture and 2 anterior sutures were placed with 0 silk, closing the hiatus down to a loose fit around the esophagus and bougie. A posterior suture was placed at the GE junction and down to the caudal portion of the hiatal closure. A tacking suture was also placed from the anterior portion of the phrenoesophageal ligament up to the anterior closure as well. An EGD was then performed. There was an excellent appearance to the hiatus without evidence of hernia. There was also no evidence of air bubbling or leakage from the esophagus or gastric sleeve. The remainder the abdomen was carefully explored. There was some vague injection to the vessels of the right lower quadrant. An area of this peritoneum and injected vessels were excised with the harmonic scalpel and sent for pathologic exam. The appendix appeared normal, however due to the persistent pain, and appendectomy was performed. The harmonic scalpel is used to divide the mesoappendix and the appendix ligated with PDS Endo loops. The appendix was then divided and removed. The ileum was then run and inspected. There was no further evidence of pathology. The gynecologic organs are surgically absent as was the gallbladder. The abdomen was then desufflated and all ports removed. Skin sites were closed with subcuticular 4-0 Monocryl. Steri-Strips and sterile dressings were applied. Patient tolerated the procedure well"
THANK YOU in advance for any input!!
"Under adequate general anesthetic, the abdomen was prepped and draped in the usual sterile fashion. 25% bupivacaine with epinephrine was injected throughout for postop pain control. A left lower abdominal 5 mm optic view trocar was placed under direct vision and the abdomen insufflated with CO2 to pressure 15 cm of water. A subxiphoid Nathanson liver retractor was placed under direct vision and used to elevate the left lobe of the liver. Gross expiration the abdomen revealed no obvious pathology or injury. A hiatus was inspected and did appear to have a moderate-sized hiatal hernia with gastric sleeve herniated into the mediastinum. A left-sided 5 mm port and right-sided 5 and 10 mm port replaced under direct vision as well. The harmonic scalpel was used to dissect the hiatus circumferentially. The crura were identified posteriorly and the moderately enlarged hiatus dissected circumferentially as well. The hernia sac and phrenoesophageal ligament were divided, taking care to identify preserved vagus nerves. Dissection was carried up into the mediastinum and esophagus for several centimeters, allowing persistent reduction of the hernia. A 36 and then a 56 French bougie were placed into the esophagus for sizing purposes. A posterior suture and 2 anterior sutures were placed with 0 silk, closing the hiatus down to a loose fit around the esophagus and bougie. A posterior suture was placed at the GE junction and down to the caudal portion of the hiatal closure. A tacking suture was also placed from the anterior portion of the phrenoesophageal ligament up to the anterior closure as well. An EGD was then performed. There was an excellent appearance to the hiatus without evidence of hernia. There was also no evidence of air bubbling or leakage from the esophagus or gastric sleeve. The remainder the abdomen was carefully explored. There was some vague injection to the vessels of the right lower quadrant. An area of this peritoneum and injected vessels were excised with the harmonic scalpel and sent for pathologic exam. The appendix appeared normal, however due to the persistent pain, and appendectomy was performed. The harmonic scalpel is used to divide the mesoappendix and the appendix ligated with PDS Endo loops. The appendix was then divided and removed. The ileum was then run and inspected. There was no further evidence of pathology. The gynecologic organs are surgically absent as was the gallbladder. The abdomen was then desufflated and all ports removed. Skin sites were closed with subcuticular 4-0 Monocryl. Steri-Strips and sterile dressings were applied. Patient tolerated the procedure well"
THANK YOU in advance for any input!!