Amity, OR
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Hello, could someone please help me. I've been thrown into surgery coding and I have no idea what I'm doing.

PROCEDURE: Laparoscopic converted to open small bowel resection

INDICATIONS: history of laparoscopic sleeve gastrectomy converted to gastric bypass in Tijuana, Mexico on 4/24/2023. She did well postoperatively for about 3 weeks and then presented to our hospital with 2 days of worsening abdominal pain and distention. CT showed evidence of obstruction of her BP limb at the JJ anastomosis. She was taken for laparoscopic exploration and found to have a twisting of her JJ anastomosis creating obstruction. This was unable to be remedied and she required resection and revision of her JJ anastomosis. She subsequently was able to tolerate a diet although continued to have some abdominal distention and dilated loops of small bowel. Contrast was able to traverse to the colon and she was discharged home with short interval follow-up. She returned to the emergency department today with an acute worsening of her abdominal pain and evidence of high-grade bowel obstruction at her distal anastomosis on CT scan. She was consented for the following procedure.

The patient was taken to the operating room placed upon on the operating table. General anesthesia was induced and an endotracheal tube was placed. The abdomen is prepped and draped in usual sterile fashion. A surgical timeout was performed. Local anesthesia was instilled at the prior incision at the umbilicus. This was reopened using an 11 blade. The abdomen was entered safely under direct visualization using a 5 mm optical entry trocar. Upon entry to the abdomen it was clear that there was very little working space due to largely dilated bowel. There was visible bilious ascites. There was small bowel which was densely adherent to the anterior abdominal wall in the right upper abdomen. There was some fibrinous exudate and a fair amount of inflammation in this area which caused concern for possible contained perforation which had walled off against the abdominal wall. At this point the decision was made to convert to an open procedure.

The generous midline incision was made extending superior and inferior to the umbilicus. Subcutaneous tissues were divided. The fascia was identified and divided in the midline using electrocautery. An Alexis wound protector was placed. Immediately there was a very dilated loop of small bowel which eviscerated through the wound. As this was manipulated a serosal tear was created which was reapproximated using 2-0 silk interrupted sutures. Distal decompressed bowel was identified and run proximally to the more distal anastomosis. This appeared to have scarred down to the retroperitoneum in such a way that the common channel was kinked off. As this was reoriented there was some passage of contents distally but the opening continued to be quite stenotic. There was also found to be an approximately 2 to 3 mm hole at the common enterotomy where this had broken down. This was gently opened with a hemostat and a pool suction was passed to decompress the biliopancreatic limb and the more proximal Roux limb. The hole was then closed with a figure-of-eight silk to avoid further spillage. The remainder of the BP limb appeared pink, healthy, and viable. It was peristalsing once decompressed. The Roux limb was then run proximally towards the more proximal anastomosis. This was densely adherent to the anterior abdominal wall. This was gently taken down with finger fracture technique and as we did this discovered a quarter size enterotomy which was the previous site of the common enterotomy which had broken down and walled off against the anterior abdominal wall. The pull suction was passed through the enterotomy and the proximal Roux limb was decompressed. The enterotomy was then closed with figure-of-eight silk suture to avoid further spillage.

At this point the decision was made to resect both anastomoses and reconstruct. The BP limb, Roux limb, and common channel were all marked with unique suture material. A window was made in the mesentery and the bowel was divided on each side of the anastomosis using 60 mm blue load Endo GIA stapler. The mesentery was divided using the Enseal device. This was repeated with a second anastomosis. Both anastomoses were then passed off as specimen. There was approximately 30 to 40 cm of intervening small bowel between the 2 anastomoses. I considered resecting this as well, to spare her an additional anastomosis, however I was concerned about maintaining adequate bowel length, so I elected to keep this. At this point all of her small intestine was pink, pulsating, and peristalsing. Continuity of the Roux limb/common channel was reestablished by creating 2 side-to-side functional end-to-end anastomoses. The anastomoses were created using 60 cm blue load Endo GIA stapler and common enterotomies were closed using running 2-0 Vicryl suture.

The BP limb was then reanastomosed to the Roux limb/common channel at a point in the intervening small bowel between the 2 prior anastomoses. This is created in the same fashion. This left her with approximately 90 cm Roux limb and a little over 100 cm common channel. BP limb was difficult to measure due to dense adhesions in this area and I elected not to pursue this further for fear of creating an enterotomy. At this point the abdomen was copiously irrigated using 5 L of warmed normal saline until effluent ran clear. Hemostasis was ensured. Two 19 French round fluted Blake drains were placed through her previous laparoscopic sites in the right lower abdomen in the right upper abdomen. The lower drain was positioned in the pelvis. The upper drain was positioned along the upper abdomen adjacent to the anastomoses and into the left paracolic gutter. Drains were secured in place using 3-0 nylon suture and placed to bulb suction.

Fascia was reapproximated using running #0 PDS suture. Local anesthesia was instilled using 0.5% Marcaine with epinephrine. The wound was copiously irrigated and hemostasis was ensured. Skin was reapproximated using skin staplers and dressed with Xeroform gauze, 4 x 4's, and Medipore tape. Drain sponges drains were dressed with drain sponges and Medipore tape.

The patient was awakened, extubated, and transferred to the PACU in good condition.

All counts were correct at the end of the procedure.