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Lap Heller Myotomy, VATS/with resection of esophageal diverticulum

  1. #1
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    Question Lap Heller Myotomy, VATS/with resection of esophageal diverticulum
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    not sure of the VATS w/resection of esophageal diverticulum - any ideas??

    INDICATIONS FOR PROCEDURE: The patient has findings of a large esophageal diverticulum. She has significant dysphagia and trapping of food within this diverticulum. She presents for resection of this. There is a presumed motility issue. So plan is for myotomy at the same setting. We will attempt to resect the diverticulum transhiatal, but likely we will require video-assisted thoracoscopy.
    *
    DESCRIPTION OF PROCEDURE: After the risks, benefits, alternatives, potential complications were explained in detail to the patient, consent was given. The patient was identified, brought to the operative suite and placed supine in the bed. After adequate anesthesia was obtained, the abdomen was prepped with chlorhexidine and draped in normal fashion. A stab incision was made to the left of the umbilicus and a bladeless 5-mm trocar was inserted intraperitoneally. Pneumoperitoneum was created with CO2 insufflation to 15 mmHg pressure with good 4 quadrant tympany. Under direct vision with the laparoscope, a subxiphoid 5 mm, 2 right upper quadrant, one 5, one 10 mm and 2 left upper quadrant 5 mm stab incisions were made and trocars were inserted into the abdomen. The abdomen was explored. There was no other obvious pathology. There was an obvious hiatal hernia. The clear area of the gastrohepatic ligament was opened overlying the right crus of the diaphragm. Dissection was carried up along the right crus of the diaphragm, taking down the hiatal hernia sac. We carried our dissection anteriorly, taking down the phrenoesophageal ligament. We then reflected the fundus of the stomach medially. We then took down the high short gastric vessels with Harmonic scalpel dissection mobilizing the fundus. We then carried our dissection up along the left crus of the diaphragm connecting this with our prior dissection. We mobilized the distal esophagus down into the abdomen as much as possible completely reducing the hiatal hernia. Care was taken to avoid any injury to vagus nerves. We could not identify an obvious diverticulum. We felt we were at the inferior aspect of this. At this point, an intraoperative EGD was performed and this confirmed this finding. Via the transhiatal approach, we can only get to the lower aspect of the diverticula.
    *
    Attention was then turned to performance of the myotomy. The fat pad at the GE junction was cleared anteriorly. The longitudinal muscular fibers of the esophagus were opened and then the circular fibers divided. The circular fibers were quite dense. This was freed up down to the mucosal layer starting about a 1 cm onto the stomach and extending up about 7 cm. EGD was once again performed with air insufflation under water and saw no evidence of leak from the mucosa. Following this, crura was reapproximated with a 2-0 silk suture. A Dor type fundoplication was then performed with a running and interrupted 0 silk suture. Hemostasis was assured throughout. With hemostasis assured, pneumoperitoneum was allowed to desufflate. Liver retractor and trocars were removed. The skin of all incisions closed with subcuticular 4-0 Monocryl. The patient was then repositioned in left lateral decubitus position. The chest was prepped and draped in the normal fashion. A small stab incision was made approximately the 7th intercostal interspace in the posterior axillary line and an optical trocar system was inserted into the pleural space with the right lung, not being ventilated. Under direct vision with the thoracoscope 2 more superior and posterior one 10 and one 5 mm and 2 more superior anterior 5-mm stab incisions were made and Thoracoports inserted into the chest. The lung was retracted medially. We dissected out the esophagus and we opened the pleura overlying the esophagus. We identified a huge diverticulum just above the extent of our transhiatal dissection. This was freed from surrounding tissues circumferentially. We had left the endoscope in the esophagus as a guide. Using careful Harmonic scalpel, sharp and blunt dissection, we freed the diverticulum up from surrounding tissues. We then opened the musculature around the base of the diverticulum. The esophageal diverticulum was then resected with successive firings of an Echelon stapler. It was removed via endoscopic bag via the larger Thoracoport site incision. The staple line was then oversewed closing the musculature over this with a running 2-0 Vicryl suture. Hemostasis was assured throughout. The area was tested with air insufflation underwater and there was no evidence of leak. A chest tube was placed posteriorly and the lung allowed to reexpand. Thoracoports were removed. The larger incision was closed with deep layers of 0 Vicryl suture. The skin of all incisions closed with subcuticular 4-0 Monocryl. Dressing, Steri-Strips and gauze were applied. The patient tolerated the procedure well. There were no complications. She was transferred to recovery area stable.
    *

  2. #2
    Default Lap Heller Myotomy, VATS/with resection of esophageal diverticulum
    Quote Originally Posted by lindacoder View Post
    not sure of the VATS w/resection of esophageal diverticulum - any ideas??

    INDICATIONS FOR PROCEDURE: The patient has findings of a large esophageal diverticulum. She has significant dysphagia and trapping of food within this diverticulum. She presents for resection of this. There is a presumed motility issue. So plan is for myotomy at the same setting. We will attempt to resect the diverticulum transhiatal, but likely we will require video-assisted thoracoscopy.
    *
    DESCRIPTION OF PROCEDURE: After the risks, benefits, alternatives, potential complications were explained in detail to the patient, consent was given. The patient was identified, brought to the operative suite and placed supine in the bed. After adequate anesthesia was obtained, the abdomen was prepped with chlorhexidine and draped in normal fashion. A stab incision was made to the left of the umbilicus and a bladeless 5-mm trocar was inserted intraperitoneally. Pneumoperitoneum was created with CO2 insufflation to 15 mmHg pressure with good 4 quadrant tympany. Under direct vision with the laparoscope, a subxiphoid 5 mm, 2 right upper quadrant, one 5, one 10 mm and 2 left upper quadrant 5 mm stab incisions were made and trocars were inserted into the abdomen. The abdomen was explored. There was no other obvious pathology. There was an obvious hiatal hernia. The clear area of the gastrohepatic ligament was opened overlying the right crus of the diaphragm. Dissection was carried up along the right crus of the diaphragm, taking down the hiatal hernia sac. We carried our dissection anteriorly, taking down the phrenoesophageal ligament. We then reflected the fundus of the stomach medially. We then took down the high short gastric vessels with Harmonic scalpel dissection mobilizing the fundus. We then carried our dissection up along the left crus of the diaphragm connecting this with our prior dissection. We mobilized the distal esophagus down into the abdomen as much as possible completely reducing the hiatal hernia. Care was taken to avoid any injury to vagus nerves. We could not identify an obvious diverticulum. We felt we were at the inferior aspect of this. At this point, an intraoperative EGD was performed and this confirmed this finding. Via the transhiatal approach, we can only get to the lower aspect of the diverticula.
    *
    Attention was then turned to performance of the myotomy. The fat pad at the GE junction was cleared anteriorly. The longitudinal muscular fibers of the esophagus were opened and then the circular fibers divided. The circular fibers were quite dense. This was freed up down to the mucosal layer starting about a 1 cm onto the stomach and extending up about 7 cm. EGD was once again performed with air insufflation under water and saw no evidence of leak from the mucosa. Following this, crura was reapproximated with a 2-0 silk suture. A Dor type fundoplication was then performed with a running and interrupted 0 silk suture. Hemostasis was assured throughout. With hemostasis assured, pneumoperitoneum was allowed to desufflate. Liver retractor and trocars were removed. The skin of all incisions closed with subcuticular 4-0 Monocryl. The patient was then repositioned in left lateral decubitus position. The chest was prepped and draped in the normal fashion. A small stab incision was made approximately the 7th intercostal interspace in the posterior axillary line and an optical trocar system was inserted into the pleural space with the right lung, not being ventilated. Under direct vision with the thoracoscope 2 more superior and posterior one 10 and one 5 mm and 2 more superior anterior 5-mm stab incisions were made and Thoracoports inserted into the chest. The lung was retracted medially. We dissected out the esophagus and we opened the pleura overlying the esophagus. We identified a huge diverticulum just above the extent of our transhiatal dissection. This was freed from surrounding tissues circumferentially. We had left the endoscope in the esophagus as a guide. Using careful Harmonic scalpel, sharp and blunt dissection, we freed the diverticulum up from surrounding tissues. We then opened the musculature around the base of the diverticulum. The esophageal diverticulum was then resected with successive firings of an Echelon stapler. It was removed via endoscopic bag via the larger Thoracoport site incision. The staple line was then oversewed closing the musculature over this with a running 2-0 Vicryl suture. Hemostasis was assured throughout. The area was tested with air insufflation underwater and there was no evidence of leak. A chest tube was placed posteriorly and the lung allowed to reexpand. Thoracoports were removed. The larger incision was closed with deep layers of 0 Vicryl suture. The skin of all incisions closed with subcuticular 4-0 Monocryl. Dressing, Steri-Strips and gauze were applied. The patient tolerated the procedure well. There were no complications. She was transferred to recovery area stable.
    *
    There are a couple different ways you could bill the VATS esophageal diverticulectomy portion. You could look at using either 32662 (equating the diverticula as a cystic or mass like structure) or using an unlisted code and comparing it to either CPT 43135 or 43180. An argument could be made to use CPT 43135 for this as the CPT description doesn't specify open approach only that the approach is made via the chest wall. Since VATS incisions are placed in the chest wall that is technically a thoracic approach.

    Hope this helps!
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

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