Laparoscopy/Laparotomy, reduction of stomach from chest

rgeib

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Looking for some advice on the following:

POSTOPERATIVE DIAGNOSIS: Gastric volvulus with cachexia

ANESTHESIA: general anesthesia, single-lumen tube.

OPERATION PERFORMED:
Gatroscopy with lavage to remove barium followed by laparoscopy and led to laparotomy with mobilization of stomach out of the chest and fixation into the abdomen with pyloromyotomy and feeding jejunostomy as well as lysis of adhesions.

SALIENT OPERATIVE FINDINGS:
Gastroscopy revealed that there was no fluid in the stomach. There was evidenced of almost a volvulus with the gastroscope. Looking back itself, we were able to find the pylorus and used to go through this. There did appear to be some redundancy in the distal stomach. We then performed a laparoscopy, identified that there was a wide hiatus with the omentum going up into the chest. There was normal orientation of the stomach at the gastroepiploic vessel was the conduit vessel on the left side of the stomach as it went up into the hiatus. We did identify bands with the hiatus, which we divided. This allowed us to mobilize the stomach well out of the chest and we then tacked it to the diaphragm and to the crus in the abdomen, so that we would maintain a straight orientation. This was then identified with the gastroscope as well. As well, we performed a pyloromyotomy and then we performed a jejunostomy tube. There were multiple adhesions to the abdomen that were lysed as well. We took down the old jejunostomy tube site.

OPERATIVE NOTE:
The patient was brought to the operating room, underwent general anesthesia and single-lumen endotracheal intubation. A time-out and safety pause were then performed, conforming to universal protocol. We then passed the gastroscope down through the mouth and visualized a 30 cm evidence of a mild esophageal gastric stenosis. We were able to pass through this, we entered into the stomach and found that we were often looking back at it and was likely gastric volvulus. However, there was no food in the stomach and we were able to enter the pylorus without difficulty. We left the gastroscope in place. We then prepped and draped the abdomen in normal fashion. We then performed a midline abdominal incision. We placed the laparoscope in place. We were able to see that there was a wide hiatus with omentum in the stomach going up into the hiatus. We had difficulty, however, mobilizing the stomach into the abdomen with laparoscopy.
I felt that there were need for counter traction. I did not want to put an instrument on his stomach because I was concerned about tearing and causing a gastric perforation.
We therefore made a midline abdominal incision. We then entered up and identified the hiatus was wide. We were able to identify adhesions, particularly on the lesser curvature side of the stomach up into the chest and these were lysed with electro-cautery. We also brought the stomach well down into the abdomen. It was then sutured in place with a suture of 0 Ethibond, tacking it to the anterior aspect of the diaphragm as well as tacking it to the crus. We then performed a pyloromyotomy to confirm there was no evidence of pyloric outlet obstruction. We did check for air insufflation into the stomach and found no evidence of any leak. After this was done, we felt it important to decompress the bowel. We divided some adhesions simply in order to prevent a small bowel distension and then placed a jejunostomy tube in place approximately 20 cm distal to our ligament of Treitz and also another 10 cm proximal to the area of the previous feeding jejunostomy tube, which had been placed by laparoscopic approach. The Jackson-Pratt #10 drain was placed in the jejunostomy to function as a jejunostomy tube. This was placed through the antimesenteric side of the proximal small bowel with a 3-0 Vicryl pursestring suture followed by interrupted 3-0 silk sutures as a Witzel tunnel. This was inserted through the abdominal wall with 30 silk sutures an anti-torsion suture was also placed. .
During this, we then checked for bleeding which was minimal. We irrigated the abdomen. We lost approximately 250 ML of blood. We then mobilized the fascia and closed the abdominal fascia with #1 PDS all the way.
We repaired the linea alba with a running continuous 0 PDS suture and applied staples to the skin.
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Since the laparoscopy was converted to an open procedure, I came up with 44050 for the stomach reduction, 43520 for the pyloromyotomy, and 44300 for the jejunostomy tube. My encoder shows no bundling issues here, but I'm not 100% sure about 44300 or if the procedure is more work-intensive than 44050. Any help would be appreciated. Thanks.
 
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