ksrkelly7
Networker
Hi there...
This is my first post. Could I please get some help on coding this report?
Indication for Surgery
pancreatic cancer
Preoperative Diagnosis
pancreatic cancer
Postoperative Diagnosis
metastatic pancreatic cancer, unresectable
Operation
exploratory laparotomy
cholecystectomy
hepaticojejunostomy via roux Y limb
loop gastrojejunostomy
biopsy of retroperitoneal mass
Findings
large metastatic nodes in the aortocaval window, positive on frozen section making tumor stage IV and surgically unresectable
Specimen(s)
aortocaval nodes biopsy
peritoneal nodule in lesser sac
Technique
After informed consent patient brought to OR and given preoperative antibiotics and general anesthesia. Anesthesia placed a central line and a line. Foley was placed. The abdomen was prepped with chloraprep and allowed to dry for 3 minutes before draping in sterile fashion. I placed ioband. I did a right subcostal incision with a 10 scalpel and divided abdominal wall with cautery and ligasure. Bookwalter retractor placed and abdomen inspected. No metastatic disease found on initial palpation of the peritoneum and liver. I mobilized the right colon up and divided the gastrocolic ligament to identify the posterior stomach. The colon was packed downwards with the retractor. I then widely Kocherized the duodenum to the aorta posteriorly. The mass was felt in the uncinate process. The mass was very large. There was large confluent suspicious lymph nodes down the aortocaval window below the left renal vein. A portion of one of these nodes was resected and frozen section shows metastatic adenocarcinoma. At that point the decision was made not to proceed with full Whipple surgery. The patient has bilirubin of 9 and needs biliary bypass so a roux Y limb was constructed by dividing the bowel 15 cm distal to LOT, making a 30 cm roux limb and reconnecting the jejunojejunostomy with a side to side stapler and closing enterotomy with 3-0 PDS layer and inverting 3-0 silk. The end of the roux limb was brought through the hepatic flexure mesocolon and up to the CBD area. A cholecystectomy was done in a dome down fashion. The cystic artery was clipped and divided. The cystic duct was tied with 2-0 silk and stump oversewn with 3-0 PDS also, gallbladder sent for permanent pathology. I then opened anterior CBD and sutured it to the roux Y limb of jejunum in a side to side fashion with running 4-0 PDS. The anastomosis was checked with hydrogen peroxide and was not leak. I then found a portion of the jejunum 15 cm distal to the jejunojejunostomy and brought it to the retrogastric position under the transverse mesocolon. A nodule that is suspicious for metastatic peritoneal disease found on posterior stomach and sent for permanent and sutured the serosal hole shut with silk. The gastrojejunostomy was done with stapled side to side with 75 stapler and closed the enterotomy with 3-0 PDS and out 3-0 silk. The abdomen was then irrigated. One 10 F JP placed from the right abdomen to the bile duct anastomosis. All instrument and lap counts were correct x 2. I closed the fascia with 2 layers of running #1 PDS, skin with subdermal 2-0 vicryl and skin staples. Dressings applied and patient taken to recovery in stable condition.
I'm thinking 47760, 43820. I believe the 49010 is bundled as is the 47600. What about the 38747? Any help with this would be greatly appreciated.
Thanks,
Kelly C, CPC-A
This is my first post. Could I please get some help on coding this report?
Indication for Surgery
pancreatic cancer
Preoperative Diagnosis
pancreatic cancer
Postoperative Diagnosis
metastatic pancreatic cancer, unresectable
Operation
exploratory laparotomy
cholecystectomy
hepaticojejunostomy via roux Y limb
loop gastrojejunostomy
biopsy of retroperitoneal mass
Findings
large metastatic nodes in the aortocaval window, positive on frozen section making tumor stage IV and surgically unresectable
Specimen(s)
aortocaval nodes biopsy
peritoneal nodule in lesser sac
Technique
After informed consent patient brought to OR and given preoperative antibiotics and general anesthesia. Anesthesia placed a central line and a line. Foley was placed. The abdomen was prepped with chloraprep and allowed to dry for 3 minutes before draping in sterile fashion. I placed ioband. I did a right subcostal incision with a 10 scalpel and divided abdominal wall with cautery and ligasure. Bookwalter retractor placed and abdomen inspected. No metastatic disease found on initial palpation of the peritoneum and liver. I mobilized the right colon up and divided the gastrocolic ligament to identify the posterior stomach. The colon was packed downwards with the retractor. I then widely Kocherized the duodenum to the aorta posteriorly. The mass was felt in the uncinate process. The mass was very large. There was large confluent suspicious lymph nodes down the aortocaval window below the left renal vein. A portion of one of these nodes was resected and frozen section shows metastatic adenocarcinoma. At that point the decision was made not to proceed with full Whipple surgery. The patient has bilirubin of 9 and needs biliary bypass so a roux Y limb was constructed by dividing the bowel 15 cm distal to LOT, making a 30 cm roux limb and reconnecting the jejunojejunostomy with a side to side stapler and closing enterotomy with 3-0 PDS layer and inverting 3-0 silk. The end of the roux limb was brought through the hepatic flexure mesocolon and up to the CBD area. A cholecystectomy was done in a dome down fashion. The cystic artery was clipped and divided. The cystic duct was tied with 2-0 silk and stump oversewn with 3-0 PDS also, gallbladder sent for permanent pathology. I then opened anterior CBD and sutured it to the roux Y limb of jejunum in a side to side fashion with running 4-0 PDS. The anastomosis was checked with hydrogen peroxide and was not leak. I then found a portion of the jejunum 15 cm distal to the jejunojejunostomy and brought it to the retrogastric position under the transverse mesocolon. A nodule that is suspicious for metastatic peritoneal disease found on posterior stomach and sent for permanent and sutured the serosal hole shut with silk. The gastrojejunostomy was done with stapled side to side with 75 stapler and closed the enterotomy with 3-0 PDS and out 3-0 silk. The abdomen was then irrigated. One 10 F JP placed from the right abdomen to the bile duct anastomosis. All instrument and lap counts were correct x 2. I closed the fascia with 2 layers of running #1 PDS, skin with subdermal 2-0 vicryl and skin staples. Dressings applied and patient taken to recovery in stable condition.
I'm thinking 47760, 43820. I believe the 49010 is bundled as is the 47600. What about the 38747? Any help with this would be greatly appreciated.
Thanks,
Kelly C, CPC-A