Hello everyone,

We have an unusual case: a patient with a history of open AAA repair presents with new perivisceral aneurysm, surgeon decides bilateral renal debranching staged with a 2 vessels FEVAR. Co-surgery needed due to difficulty, both reports are consistent:
1. Extensive enterolysis. Adhesiolysis of the intra-abdominal content.
2. Right renal artery bypass by the way of gastroduodenal artery with an end-to-end anastomosis.
3. Splenorenal artery bypass to the left renal artery in end-to-side fashion.
After consent was obtained, the patient was brought back to the operative suite where he was placed on the table in the operating suite where he underwent epidural placement by anesthesia. Monitoring lines were also placed after this, and after adequate general anesthesia, the patient's abdomen and chest were prepped and draped in normal standard fashion. A time-out was performed and antibiotics were given less than 1 hour prior to skin incision. Next, a chevron incision was made in the right and left subcostal area, and then this was deepened through the subcutaneous tissue and muscle with the electrocautery. After we got into the peritoneal cavity, we encountered significant amount of adhesions from his prior abdominal surgeries. These were taken down sharply with electrocautery. This was quite difficult and added over an hour and a half to the case just getting into these adhesions. After adequate adhesiolysis, the bowel was run. The ligament of Treitz down to the ileocecum and it appeared to be normal. We did encounter a little bit of bleeding from the liver and this was controlled with the argon beam. We are then able to identify the hepatic artery, proximal to it where branches entered the gastroduodenal artery and proper hepatic artery. This was identified just cephalad to the pylorus was easily palpable. We were able to dissect out greater than 3 cm length of the gastroduodenal artery. We were able to get proximal and distal control with vessel loops. We were able to include the level of the gastroduodenal artery distally that was at a branch point. We then dissected out right renal artery, and the adrenal was right there off of the aorta and this was ligated with 2-0 silks. We were able to gain circumferential control just near the aorta and right renal artery origin. This was encircled with vessel loops and then we were able to get about 2.5 cm dissect out circumferentially the right renal artery to where it branched first. This was also then circumferentially dissected out and encircled with vessel loops. We then proceeded to the left side. We then entered the lesser sac on the left, and were able to identify the pancreas, retracting the pancreas inferiorly. We were able to identify the splenic artery. We got proximal and distal control and dissected out for an adequate length for bypass and proceeded to identify the left renal artery. The left renal artery was a little more difficult to identify as it had been pushed inferior and lateral secondary to his aneurysm, which was large. We were able to identify it out. We are not able to really dissect down much more length and there was a short renal artery. At this time, we dissected this out as for the adequate length as possible, and encircled with vessel loops. At this time, we then proceeded to heparinize the patient as we are ready to proceed with our bypasses. The renal artery was ligated proximally close to the takeoff from the origin from the aorta and then end-to-side anastomosis was performed of the splenic artery using a 5-0 Prolene suture. The standard and flushing maneuvers were performed prior to finishing her anastomosis and then, the suture was tied down and flow was restored back. After 3 minutes of being fully heparinized, the proximal and distal areas were clamped prior to perform our anastomosis. After standard flushing maneuvers, the clamps were removed and blood flow was restored to the kidney. There was seem to be good flow in this area and there was good hemostasis, which was obtained also with the help of thrombin-soaked Gelfoam. We then proceeded to the right side and the gastroduodenal artery was clamped proximally and dissected out and ligated distally for an appropriate length. The right renal artery was dissected off and clamp distally and suture-ligated proximally and cut for appropriate length. We then performed end-to-end anastomosis of the right renal artery through the gastroduodenal artery after spatulating the edges. We performed our end-to-end anastomosis with 5-0 Prolene. Standard flushing maneuvers were performed prior to completing our anastomosis. We then completed our anastomosis and the vessels were unclamped and blood flow was restored to the right kidney. There seemed to be a good flow in this area. At this time, we performed a limited ultrasound of the bypasses and they appeared to be patent. This was done with the assistance of the peripheral vascular lab. We had good flow. Then, we reversed the patient's heparin with 10 of protamine..."
Codes: 35636-22 for the left side (splenic to renal anastomosis) and unlisted 37799 for the right side (with 35281-22 as comparable).
Any help would be appreciated.
Thank you.