knperry
Guru
A laparoscopic appendectomy was started but due to the inflamed state and poor tissue the appendix was pulled off the base so the procedure was converted to a midline laparotomy. Now I know the codes to use are 44970 for closed and 44950 for open but I'm not sure which modifier to add to the 44970. Surgical notes are below:
DESCRIPTION OF PROCEDURE IN DETAIL: Mr. Perezojeda was taken back to the operating room, placed on the OR table in supine position. General endotracheal anesthesia was administered. Patient was then prepped and draped in the usual sterile fashion. A timeout was performed. A 12-mm incision was made over the umbilicus and blunt dissection was taken down to the fascia, which was sharply incised with a blade and a Kelly was used to enter the peritoneal space. A 12-mm balloon trocar was then inserted through this incision into the intraperitoneal space and CO2 insufflation was started through this port. After insufflation, a 10-mm scope was passed through this trocar, which revealed that we were indeed in the intraperitoneal space and there were no bowel injuries upon entry. At this point, a 5-mm trocar was placed just above the dome of the bladder and another 5-mm port was placed in between these 2 ports just lateral to the rectus muscle on the left side. Using these 3 ports, 2 graspers were used to find the appendix, which appeared very inflamed and thickened. We then worked on freeing the appendix up from all surrounding adhesions. The areas and tissue were very frail and friable. We eventually got into minor amount of bleeding. However, we were able to control this bleeding just by grasping the vessel of the mesoappendix. We then created a window between the appendix and the mesoappendix and then had a white load stapler fired through this area. Bleeding at this point was well
controlled. We then focused our attention on dissecting out the rest of the appendix to the base of the cecum. Base of the cecum was visualized and we were set to divide the appendix from the base of the cecum with a blue load stapler. However, at this point, the appendix was accidentally pulled off the base of the appendix due to the inflamed state and poor tissues. We then decided to try to put a box stitch around the site, where the appendix was attached. However, visualization and exposure was very difficult laparoscopically, so thus we converted to a midline laparotomy. A midline laparotomy was carried out from the umbilical port site that was above the dome of the bladder. We then carried this all the way down past the fascia into the intraperitoneal space and now we were able to use retractors and gain good visualization of the base of the cecum where the appendix was pulled off. At this point, we used 3-0 silk sutures in order to bring the serosa of the injured side of the cecum together. After this, the side of the appendix was clearly visualized and was closed using those 3-0 silk sutures. We then irrigated this area copiously with saline and then we focused our attention on
closing the fascia. Fascia was closed in a running fashion using looped PDS. After fascial closure, we irrigated the wound copiously with saline and used staples to close the midline incision. We also stapled the remaining 5-mm ports lateral to the midline. This then concluded the end of our procedure.
Patient was then transferred to the PACU and extubated in stable state.
DESCRIPTION OF PROCEDURE IN DETAIL: Mr. Perezojeda was taken back to the operating room, placed on the OR table in supine position. General endotracheal anesthesia was administered. Patient was then prepped and draped in the usual sterile fashion. A timeout was performed. A 12-mm incision was made over the umbilicus and blunt dissection was taken down to the fascia, which was sharply incised with a blade and a Kelly was used to enter the peritoneal space. A 12-mm balloon trocar was then inserted through this incision into the intraperitoneal space and CO2 insufflation was started through this port. After insufflation, a 10-mm scope was passed through this trocar, which revealed that we were indeed in the intraperitoneal space and there were no bowel injuries upon entry. At this point, a 5-mm trocar was placed just above the dome of the bladder and another 5-mm port was placed in between these 2 ports just lateral to the rectus muscle on the left side. Using these 3 ports, 2 graspers were used to find the appendix, which appeared very inflamed and thickened. We then worked on freeing the appendix up from all surrounding adhesions. The areas and tissue were very frail and friable. We eventually got into minor amount of bleeding. However, we were able to control this bleeding just by grasping the vessel of the mesoappendix. We then created a window between the appendix and the mesoappendix and then had a white load stapler fired through this area. Bleeding at this point was well
controlled. We then focused our attention on dissecting out the rest of the appendix to the base of the cecum. Base of the cecum was visualized and we were set to divide the appendix from the base of the cecum with a blue load stapler. However, at this point, the appendix was accidentally pulled off the base of the appendix due to the inflamed state and poor tissues. We then decided to try to put a box stitch around the site, where the appendix was attached. However, visualization and exposure was very difficult laparoscopically, so thus we converted to a midline laparotomy. A midline laparotomy was carried out from the umbilical port site that was above the dome of the bladder. We then carried this all the way down past the fascia into the intraperitoneal space and now we were able to use retractors and gain good visualization of the base of the cecum where the appendix was pulled off. At this point, we used 3-0 silk sutures in order to bring the serosa of the injured side of the cecum together. After this, the side of the appendix was clearly visualized and was closed using those 3-0 silk sutures. We then irrigated this area copiously with saline and then we focused our attention on
closing the fascia. Fascia was closed in a running fashion using looped PDS. After fascial closure, we irrigated the wound copiously with saline and used staples to close the midline incision. We also stapled the remaining 5-mm ports lateral to the midline. This then concluded the end of our procedure.
Patient was then transferred to the PACU and extubated in stable state.