Repair of Duodenal ulcer with Omental flap


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I need help with this.

This 70-year-old woman was brought to the operating room. She was place in the supine position. Her abdomen was prepped and draped in a satisfactory fashion. Her peritoneal cavity was carefully entered via a midline incision. There did not appear to be any gross contamination of the peritoneal cavity itself. The CT scan had suggested perforated duodenal ulcer in the retroperitoneum. I, thus, began the operation by doing a Kocher maneuver. A nasogastric tube had been placed by Anesthesia, which, was palpable, within the gastric lumen. A full Kocher maneuver was performed. I did note some edema fluid, and then I discovered air bubbles in the retroperitoneum that were originating from the posterior duodenum where I aproximated the border of the pancreas. There appeared to be some degree of penetration of the ulcer into the pancreas superficially resulting in pancreatic necrosis and what appeared to be old calcification of the pancreas itself. Some of this was gently debrided away. The ulcer defect was noted to be about 10 mm in diameter. I deceide to repair this utlizing an omental patch. Interrupted suttures of silk werer made to transverse the operning to the ulcer. In the process of placing these sutures there was a small arteriole from the duodenal wall, which started to bleed. This was controlled by oversewing it with figure-of-eight sutrues of silk. There was very little actual blood loss. A tongue of omentum was then fredd off the transverse colon and was laid across the ulcer itself. The sutures were then tied over the omentum holding it in position over the ulcer as a Graham-type patch. This completed the repair. The peritoneal cavity was then irrigated with saline. As much of the irrigation fluid as possible was aspirated back out. Final inspection showed no ongoing bleeding or other complication. At this point the omentum was placed over the bowel. The fascia was closed in a single layer utilizing running 0-loop nylon suture material. Following closure, the skin and subq tissues were further irrigated and made meticulously hemostatic with electrocautery. He goes on to say skin closed with staples.

I'm thinking of 44602 and 49906, I was looking at 44602 and 44905, however, Wisconsin Medicare, consideres these two procedures bunled.

Any help is greatly appreciated.

Thank you,