Moya Moya Procedure


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Hello All,
Does anyone know how I would code for a Moya Moya Procedure? I am thinking that I would go with
an unlisted code of 49329 with reference to CPT code 49904 but the doc stated that so much more
was done such as an additional 2 hours for the tunneling to the brain as well as harvest of pedicle flap.
Any other ideas?

1-Laparoscopic mobilization and harvest of pedicled greater omentum flap.
2-Subcutaneous tunneling towards the craniotomy via epigastric and cervical incisions.

PROCEDURE IN DETAIL: The patient was brought to the operating room and placed supine on the operating room table. A timeout was performed to ensure proper patient and procedure and laterality. A dose of preoperative antibiotics was given. General endotracheal anesthesia was then induced without any complications. A Foley catheter and OG tube were then placed. The patient was positioned in lithotomy. The abdomen, chest, neck, and right head were then prepped and draped in the usual sterile fashion. While the neurosurgery team worked on the craniotomy and exposure, we worked on the abdomen to retreive the pedicled omental flap. We accesed the abdomen via a 5 mm trans umbilical incision and pneumoperitoneum was created with a Veress needle. Upon initial laparoscopy, no obvious entry injuries were seen. Under direct visualization we then put a right and left flank 5 mm port, as well as a left upper quadrant 5 mm port in order to triangulate towards the upper abdomen. We began our dissection at the omentum starting at its attachments to the transverse colon. Being careful to preserve the blood supply from the mesocolon, we took the omentum off of the transverse colon using electrocautery. As we worked toward the splenic flexure, we saw that there were some attachments of the omentum directly to the upper pole of the spleen which were taken down with the Ligasure. We then worked towards the hepatic flexure of the colon and mobilized the other half of the omentum. Starting proximally at the high aspect of the greater curve, we used a combination of LigaSure and electrocautery to separate the omentum off of the greater curvature, preserving the right gastroepiploic artery. As we worked our way proximally up the greater curvature, we saw clearly the left gastroepiploic artery which was divided at the top of the fundus. We then worked distally along the greater curve of the stomach as the vessel became the right gastroepiploic artery and we continued our dissection until we were just left with a narrow pedicle with the right gastroepiploic artery preserved. At this point, omentum was completely mobile except for its attachments laterally to the spleen. We were very careful to inspect these attachments and to avoid the splenic hilum. Using LigaSure, we divided the vessels so that we could free the omentum. The colon looked like well perfused at the end of the case. The Endo Babcock was then placed at the distal aspect of our omental flap. We desufflated the abdomen and made an epigastric incision in order to bring out the flap. The flap was eviscerated, making sure we had no twists in the pedicle and wrapped in warm saline gauze. We then dissected down through subcutaneous tissue just above the fascia in a cephalad direction towards the base of the right neck. Using a lighted retractor and electrocautery, we developed a subcutaneous tunnel going cranially just over the xiphoid and sternum. This was extended bluntly with a long retractor and pean clamp. A counterincision was made just above the *** clavicle. We dissected down through subcutaneous space and developed a tunnel going caudally. With a combination of electrocautery and blunt dissection, we were able to connect the two tunnels from the epigastrium to the *** neck. At this point, the neurosurgeons had finished the craniotomy. They assisted us with performing our subcutaneous tunnel across the *** neck to the base of the right skull. Again, this was done with a combination of electrocautery and blunt dissection. At this point, we had a complete subcutaneous tunnel extending from the epigastrium all the way up to the cranium. We inspected the length of the omentum. The flap reached to the base of the patient's skull. To get some extra length, we divided the most inferior portion of the omentum making sure we preserved the arcades that came off the right gastroepiploic artery. With this maneuver, we gained a good length of omentum. A 0 silk tie was then tied along the most distal aspect of the omentum. Using this for retraction we were able to pull the omentum through the subcutaneous tunnel overlying the sternum and brought it out at the neck incision. We then further tunneled the omentum through the neck through the previously made subcutaneous tunnel. Without any tension the flap was able to easily cover the entire aspect of the craniotomy that was performed by the neurosurgeons. Intraoperative doppler was done to inspect the perfusion and we obtained a good biphasic signal at the omental pedicle.
We closed the neck incision, approximating the subcutaneous space with 3-0 Vicryl and closing the skin with 4-0 Monocryl being careful not to injure the omental flap. The epigastric incision was closed with an 0-Vicryl, making sure we didn't strangulate the omental pedicle. The umbilical port site fascia was closed with an 0 Vicryl suture. Skin at the port sites was closed with simple interrupted 4-0 Monocryl. The neurosurgeons were left to conclude their portion of the operation.