Gemini18
Expert
PROCEDURE: Exploratory laparotomy, resection of a small bowel
gastrointestinal stromal tumor, biopsy of additional small bowel tumor of the
jejunum and gastrostomy tube; additionally, a Ladd's procedure was done to
divide the peritoneal attachments to the duodenum.
OPERATIVE REPORT IN DETAIL: Midline incision was made. The peritoneal cavity
was entered without event. Immediately, on exploration of the abdomen, it
became evident that the large bowel was on the left side of the abdomen, the
small bowel was on the right side and that there was no evidence of attached
right colon. Exploration demonstrated that this indeed was consistent with a
diagnosis of malrotation. Peritoneal attachments that overlaid the duodenum
were noted. These were divided with cautery as a Ladd's procedure in order to
prevent any future complications of duodenal obstruction secondary to these
attachments. Next, the duodenum was fully mobilized, and it became evident
that the large index lesion that was preoperatively evaluated by both
endoscopy and CT scan was only the beginning of the problem. Just distal
about 3 cm to this index lesion, a 3-cm mass was noted on the antimesenteric
surface of the duodenum, and then subsequently on running the small bowel, the
multiple small 3-5 mm lesions were identified. Knife was utilized to biopsy
one of these smaller distal lesions and the second largest purple tumor was
excised creating a small duodenotomy that was repaired in 2 layers with 3-0
Vicryl, and then serosal sutures of 3-0 silk were utilized to reinforce this
repair. Complete exploration demonstrated that certainly the only way to
completely resect the index lesion was going to be with a
pancreaticoduodenectomy. The additional lesions, which were well distal to
the duodenum including the proximal jejunum, were multiple and precluded
complete resection. Frozen section was taken of one of the smaller lesions,
which was at frozen consistent with leiomyoma. The larger resected lesion of
the more proximal small bowel was consistent with a more ominous diagnosis,
likely leiomyosarcoma. So at this point, the conclusion was that the patient
had at least multiple leiomyomas, a large index gastrointestinal stromal tumor by outside biopsy and then this additional leiomyosarcoma. Complete resection
was felt to be beyond reason, and so the plans for pancreatic resection were
aborted. An 18-Foley was brought in through the left-sided stab incision and
placed as a gastrostomy in the anterior wall of the stomach in a standard
Witzel-type fashion. The abdomen was irrigated and the fascia was then closed
with a running #1 PDS with reinforcing sutures of #1 Vicryl. Needle, sponge
and instrument counts were correct. The patient tolerated the procedure well
and was stable at the completion of the operation.
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I have CPT codes 44120, 44110; 44020, 44361 and 44055; would this be correct?