I'm looking for opinions about how the following Operative Note should be coded.
REPORT OF OPERATION
PATIENT NAME: ACCOUNT #.:
ATTENDING PHYSICIAN: â€” MED. REC. #:â€˜
ASSISTANT: ROOM #:
PREOPERATIVE DIAGNOSIS: Massive hiatal hernia.
POSTOPERATIVE DIAGNOSIS: Massive hiatal hernia.
1. Repair of hiatal hernia.
2. Nissen fundoplication.
3. Repair of incidental esophageal tear.
4. Placement of #20 French G-tube.
5. Removal of jejunal feeding tube with repair of enterotomy.
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LESS: Less than 300 ml.
REPLACEMENT FLUIDS: 1000 ml crystalloid.
PREOPERATIVE NOTE: This patient is a 64-year-old female with massive hiatal hernia. The patients entire stomach was within the chest and the patient has inability to eat and swallow. She presents with malnutrition and dehydration. Feeding J-tube was performed, but the patient continued to have difficulties with high NG output. She was taken to the operating room now for exploration repair of the hernia. Situation, option, risks, and benefits were discussed in detail with the patient that includes risk of bleeding, infection, esophageal, stomach, and splenic injury. She does understand and wished to proceed.
OPERATIVE FINDINGS: Upon opening the abdomen and after carefully examined, in fact the entire stomach essentially the entire small bowel content, right colon, and transverse colon were within the chest and the hernia sac. The sac was quite massive with defect of the hernia itself measuring approximately 6-8 cm in greatest diameter. No other abnormalities were noted.
OPERATIVE PROCEDURE: The patient was placed on the operating table in the supine position. Anesthesia was achieved with IV induction and general endotracheal anesthesia. With the appropriate plane of anesthesia, abdomen was prepped and draped in the usual sterile fashion. A #10 scalpel blade was used to make upper midline incision through the skin and subcutaneous. Hemostasis was assured with electrocautery. Stitches from the J-tube were resected as well access to enter abdominal cavity was obtained and having carefully examined the findings as noted above.
Attention was then focused on reduction of all the contents within the chest. This was rather arduous process due to the severe adhesions. There is dense adherence of omentum in the region of the esophagus during the dissection of small rent was made in the esophagus.
Once the contents were completely reduced, the esophagus was repaired in layers using interrupted #3-0 undyed Vicryl and interrupted #3-0 silk sutures, this resulted in getting repaired. The esophagus was further mobilized for adequate length. The hernia was repaired with several #3-0 Prolene pledgeted sutures. The opening was closed to approximately 4 cm diameter. The lesser curve was mobilized and the lesser curve was brought behind the esophagus and plicated using several #2-0 silk sutures. Bites were taken on the serosa in the region of repair to buttress this as well. This resulted in secure fundoplication with no obstruction of the esophagus. The previously placed J-tube was removed and the #20 French C-tube brought through the J-tube site. Two concentric fields of pursestring sutures were placed in the body of the stomach with mild traction on the stomach to help anchor the stomach. A small gastrotomy was made with the cautery and the tube was inserted into the stomach. The pursestring sutures were then secured. A drain was instilled with 10 ml of saline. The stomach was then intact to posterior aspect of the anterior of the abdominal wall with #3-0 silk sutures and the C-tube then flushed and drained quite nicely.
A #19 French drain was placed in the hernial space and brought out to separate stab wound at the right lower costal margin. The drain was secured, skin with #2-0 nylon. #2 nylon retention sutures were placed times three followed by reapproximation of fascia with looped #0 PDS from each end of wounds. Subcutaneous was irrigated and hemostasis was assured. Skin was reapproximated with #4-0 undyed Vicryl subcuticular stitches. Benzoin and Steri-Strips were applied followed by the placement of sterile dressings.
The patient tolerated the procedure well and was in stable condition at its end. Sponge and instrument counts were noted to be correct times two.
Electronically Signed By:
Thank you in advance for your ideas!
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