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Thread: Bariatric help please

  1. #1
    Join Date
    Apr 2007
    Northeast Kansas AAPC

    Unhappy Bariatric help please

    AAPC: Back to School
    Diag. lap, lysis of adhesions, primary repair of hiatal hernia, repositioning of Lap-band and replacement of port only and intraoperative EGD. Patient has Medicare as primary insurance. Op note reads:

    Under direct visualization a 5 mm Optiview port was placed. The abdomen was insufflated with 15 cm of pressure. There were adhesions around the omentum around the catheter. These ultilmately were taken down. I did place an incision in the epigastric and a Nathanson liver retractor was placed. Prior to being able to elevate the liver, I did have to talke some adhesions down from the liver from the stomach and where the band was. 10 mm port was placed in the epigastric and a 5 mm more medial and inferior and a 5 mm left lateral subcostal. The adhesions were takend down using sharp dissection. The stomach was freed up from the liver. The liver retractor was then placed to hold this out of the way. On examination, it did look like the band had slipped anterior. The attachements over the band were taken down laterally with freeing this up. In the tissue places we did get a small opening inferiorly.This had been the bypass portion of that stomach. Therefore, there was no spillage. I did close that with a running 2-0 Vicryl. The remainder of the attachments were taken down. I then freed up the right and left crux. There was about a 2 cm hiatal hernia. After mobilizing the esophagus so that it rested in the stoamch without tension, this was then closed posteriorly with interrupted #0 silks figure-of-eight x 2. This closed it nicely without evidence of any undue tension. At this point, it was obvious that we would have to reposition the band after taking down the remainder of those attachments. The band was unbuckled and we were able to salvage it. I did cut it up where it was attached to the port and we were able to remove the band but leave it functioning. I then went more superior and made a new tract. It came out at a 45 degree anglel. The catheter was grasped. The band was brought around it. It was buckled in location and that buckle was laid to rest at the lesser curvature. I then sutured this is in location. Fortunately this was above where I had done the repair and that did not have to be buttressed up against this. I reapproximated this in a running fashion covering the anterior half of the band. Upon completion, this closed without tension. After ensuring that this all looked good, it should be stated that sewing this in location and replacing the band, we did put irrigation over where we had repaired the perforation and an EGD was done. There was no evidence of leak and the repair from the hiatal hernia looked good and no other abnormalities were seen. The band was then positioned as previously dictated and sutured in location. The catheter was grasped. It was brought out but the ** ** actually had broken off. At this point, we initially could not find it but at the end of the case it was found resting on the patient so that portion was removed. I did go ahead and make an incision over the port shite and free up the port and remove it to place a new one. Part of the intraabdominal cavity was brought out. It was attached. We then tested it to make sure there was no leaking and it filled very nicely with 4 cc and good return.
    The rest is just the closure. Any suggestions would be appreciated.


  2. #2
    Join Date
    Apr 2007
    Johnson City


    How about:

    Since the EGD was to confirm that the injury to the stomach was repaired properly, and the injury occured during lysis of adhesion, this is not separately billable. This would be similiar to "nicking the bowel during lysis of adhesions, repairing the bowel, and performing a colonoscopy or flexible sigmoidoscopy to confirm the repair is air tight.

    Hope this helps you.
    Melissa Jewett, CPC

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