ammontagano
Guru
Physician wants to bill unlisted codes to relect the open procedures of CPT codes 43631(Gastrectomy, partial, distal) and 50541 (unroofing of liver cyst). Any input would be appreciated.
DESCRIPTION OF PROCEDURE:
The patient was brought back to the operating room, placed supine. Pressure
points were padded and double checked. SCDs were functional on both lower
extremities. General anesthesia was safely established. A nasogastric tube
decompressed the stomach initially. Foot board placed. Upper Bair Hugger
placed. Arterial line and vascular access assured by the anesthesia team and
following which his abdomen was shaved, prepped, and draped in usual sterile
manner. Time-out performed. He was correctly identified for positioning,
procedure, plan, and equipment. The procedure was begun with a vertical
incision just above his umbilicus. The fascia was identified, opened
vertically, stay sutures placed, peritoneum was then entered without
complication allowing blunt Hasson trocar to be introduced, pneumoperitoneum
established, and visualization obtained with a 10 mm 30-degree laparoscopic
camera. On visualization, he was then positioned in reverse Trendelenburg,
which by using gravity to drop the omentum inferiorly, we exposed the tumor,
which was attached to the greater curvature of the fundus of the stomach.
There was no evidence of metastatic disease or other concerning lesions and
we placed 3 upper abdominal ports, pre-infiltrated with Marcaine, entering
under direct vision, including an upper midline 5 mm port and a left upper
quadrant subcostal 12 mm port, and a lateral left upper quadrant subcostal 5
mm port. All entered without complication and allowed us to then mobilize the
proximal stomach by dividing the gastrocolic and short gastric vessels and
the sheet of omentum along the greater curvature of the proximal stomach
tracing this all the way up to the left crus. Once fully mobilized, it was
clear that this should come off with a simple wedge gastrectomy. We exchanged
the nasogastric tube for an oral bougie with the anesthesia team 52-French
and this was passed down the esophagus, GE junction, and along the lesser
curve of the stomach all the way down to the antrum. This allowed us to
identify and plan the line of transection, so that we would parallel this,
but not narrow the proximal stomach significantly, but would remove the
bilobed lesion both the exophytic and the luminal growth of the tumor with 1
staple line. The Echelon stapler using blue loads with the Peri-Strips was
then used 4 firings to in essence perform a partial sleeve gastrectomy of the
gastric fundus and the staple line was intact without bleeding. The specimen
was then placed in an Endobag and set aside. The oral bougie was exchanged
for nasogastric tube, was positioned more distal to the resection of the mid
body of the stomach secured at the nose by Anesthesia. We visualized the
right upper quadrant. There was a liver lesion at the segment #8, bordering
segment 4. This appeared to be cystic in order to eliminate it from any
potential further imaging, it was unroofed and fenestrated using the Harmonic
device opening this up and releasing serous fluid. There was no blood, bile,
or any other concerning findings. No solid component. We widely unroofed it
so as to take it out of the equation when he undergoes surveillance imaging.
Upper abdomen was stable. Staple line was intact along the stomach without
complication or issue. He tolerated the partial gastrectomy well. The
abdominal ports in the upper abdomen were removed. The fascial closure device
was used with a Vicryl stitch in a figure-of-eight to close the 12 mm port.
Dermis was reapproximated with 4-0 Monocryl and we waited pathology as we
needed to widen the periumbilical incision and lengthen it to about 4 cm in
length to allow removal of the tumor. This was passed off to Pathology and
the luminal portion of the tumor felt mobile within the wedge resection
specimen. This was oriented for pathology. They grossed it, opened up the
staple line and it revealed negative margins grossly which was adequate for
oncologic surgical resection of the stromal tumor. We then closed the fascia
at the periumbilical wound with a #1 PDS from superior corners, tying it to
the inferior corner. The knot was buried by tying down the Vicryl stay
sutures. Local anesthetic, a total of 30 mL had been used. A large portion of
this was at the periumbilical incision. The incisions were closed with 4-0
Monocryl subcuticular stitches and sealed with Dermabond substitute glue. No
drains were left behind. He will keep the NG tube overnight for gastric
decompression and then start a liquid diet tomorrow. He tolerated surgery
well without any complications, problems or issues. He has been stable and I
appreciate the opportunity to be involved in his care.
DESCRIPTION OF PROCEDURE:
The patient was brought back to the operating room, placed supine. Pressure
points were padded and double checked. SCDs were functional on both lower
extremities. General anesthesia was safely established. A nasogastric tube
decompressed the stomach initially. Foot board placed. Upper Bair Hugger
placed. Arterial line and vascular access assured by the anesthesia team and
following which his abdomen was shaved, prepped, and draped in usual sterile
manner. Time-out performed. He was correctly identified for positioning,
procedure, plan, and equipment. The procedure was begun with a vertical
incision just above his umbilicus. The fascia was identified, opened
vertically, stay sutures placed, peritoneum was then entered without
complication allowing blunt Hasson trocar to be introduced, pneumoperitoneum
established, and visualization obtained with a 10 mm 30-degree laparoscopic
camera. On visualization, he was then positioned in reverse Trendelenburg,
which by using gravity to drop the omentum inferiorly, we exposed the tumor,
which was attached to the greater curvature of the fundus of the stomach.
There was no evidence of metastatic disease or other concerning lesions and
we placed 3 upper abdominal ports, pre-infiltrated with Marcaine, entering
under direct vision, including an upper midline 5 mm port and a left upper
quadrant subcostal 12 mm port, and a lateral left upper quadrant subcostal 5
mm port. All entered without complication and allowed us to then mobilize the
proximal stomach by dividing the gastrocolic and short gastric vessels and
the sheet of omentum along the greater curvature of the proximal stomach
tracing this all the way up to the left crus. Once fully mobilized, it was
clear that this should come off with a simple wedge gastrectomy. We exchanged
the nasogastric tube for an oral bougie with the anesthesia team 52-French
and this was passed down the esophagus, GE junction, and along the lesser
curve of the stomach all the way down to the antrum. This allowed us to
identify and plan the line of transection, so that we would parallel this,
but not narrow the proximal stomach significantly, but would remove the
bilobed lesion both the exophytic and the luminal growth of the tumor with 1
staple line. The Echelon stapler using blue loads with the Peri-Strips was
then used 4 firings to in essence perform a partial sleeve gastrectomy of the
gastric fundus and the staple line was intact without bleeding. The specimen
was then placed in an Endobag and set aside. The oral bougie was exchanged
for nasogastric tube, was positioned more distal to the resection of the mid
body of the stomach secured at the nose by Anesthesia. We visualized the
right upper quadrant. There was a liver lesion at the segment #8, bordering
segment 4. This appeared to be cystic in order to eliminate it from any
potential further imaging, it was unroofed and fenestrated using the Harmonic
device opening this up and releasing serous fluid. There was no blood, bile,
or any other concerning findings. No solid component. We widely unroofed it
so as to take it out of the equation when he undergoes surveillance imaging.
Upper abdomen was stable. Staple line was intact along the stomach without
complication or issue. He tolerated the partial gastrectomy well. The
abdominal ports in the upper abdomen were removed. The fascial closure device
was used with a Vicryl stitch in a figure-of-eight to close the 12 mm port.
Dermis was reapproximated with 4-0 Monocryl and we waited pathology as we
needed to widen the periumbilical incision and lengthen it to about 4 cm in
length to allow removal of the tumor. This was passed off to Pathology and
the luminal portion of the tumor felt mobile within the wedge resection
specimen. This was oriented for pathology. They grossed it, opened up the
staple line and it revealed negative margins grossly which was adequate for
oncologic surgical resection of the stromal tumor. We then closed the fascia
at the periumbilical wound with a #1 PDS from superior corners, tying it to
the inferior corner. The knot was buried by tying down the Vicryl stay
sutures. Local anesthetic, a total of 30 mL had been used. A large portion of
this was at the periumbilical incision. The incisions were closed with 4-0
Monocryl subcuticular stitches and sealed with Dermabond substitute glue. No
drains were left behind. He will keep the NG tube overnight for gastric
decompression and then start a liquid diet tomorrow. He tolerated surgery
well without any complications, problems or issues. He has been stable and I
appreciate the opportunity to be involved in his care.