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Old 07-14-2008, 11:32 AM
nlbarnes nlbarnes is offline
Join Date: Apr 2007
Location: Oceanside, CA
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Default Laparoscopic gastrectomy

Can anyone help w/ this op report please? There isn't a CPT code for laparoscopic gastrectomy and I was going to go w/ 43659 & 43235-59. Not sure about any other codes including dx code please.

Hyperplastic gastric polyps.
Hyperplastic gastric polyps.
Esophagogastroduodenoscopy and laparoscopic subtotal gastrectomy with Billroth II anastomosis.
Patient is a 58-year-old woman. She has an approximately 7 year history of gastrointestinal hemorrhage
requiring blood product replacement. She was admitted to PMC on July 1, 2008, with
recurrent symptoms. She underwent EGD by the gastroenterology service that showed diffuse polyps in her
stomach, normal duodenoscopy. Biopsy of these polyps showed hyperplasia, hyperplastic polyps. After
extensive discussion and recommendations by the gastroenterology service she elected to undergo
laparoscopic subtotal gastrectomy. The patient was admitted in the preop hold area. Questions were
answered and informed consent was obtained.
She was taken to the operating room. She received intravenous antibiotics. General
endotracheal anesthesia was induced. Foley catheter was placed. Her abdomen was prepped and draped.
We proceeded with an EGD. Gastroscope was inserted into the stomach. The esophagus was normal. The
stomach had multiple polyps centered mostly in the body, relative sparing of the fundus and antrum. The
scope was inserted in the duodenum. There was some old blood there. This was monitored with no active
source identified. We replaced the EGD with a pediatric colonoscope and inserted it into the proximal
jejunum. Once again found no additional bleeding sites. At this point the laparoscopy was started. A 10-12
port was placed in the right upper quadrant after local anesthesia. Pneumoperitoneum was created.
Additional 10-12 ports were placed in the upper abdomen and 5 mm ports laterally. A Fan liver retractor
was used to retract the left lobe of the liver. We started by taking down the short gastrics along the greater
curve up to approximately the proximal fundus level using the ligature device. This dissection was carried
distally to just distal to the pylorus. The lesser sac was freed of adhesions. A window was made in the
lesser omentum. The right gastric artery was transected with the ligature device. The dissection was carried along the lesser curve up until the proximal lesser curve arcade vessels. At this point the gastroscope was
reinserted. The proposed proximal gastric pouch was examined. It contained only a minimal number of
gastric polyps that would be easily surveyed. At this point a GIA 45 stapler was used to transect the
proximal duodenum. Additional fires with the GIA 45 stapler were used to create the proximal pouch and
resect the distal fundus and body of the stomach. Using the gastroscope the proximal pouch was examined.
There were approximately 6 to 8 remaining polyps. The pouch size was approximately 50 to 75 mL. At this
point the resected stomach was moved out of the upper abdomen and the transverse colon was lifted, the
ligament of Treitz was identified approximately 75 cm distally. The jejunum was brought up in an antecolic
fashion. Enterotomies were made in both the loop and the stomach anterior to the staple line. An additional
fire with the GIA blue load stapler was used to create a Billroth II anastomosis. The remaining enterotomy
was closed with running 2-0 Vicryl followed by interrupted 2-0 silk Lembert sutures. The anastomosis was
checked by placing the patient in Trendelenburg position using the gastroscope to insufflate the pouch
under irrigation fluid in the abdomen. There was no sign of leak and the proximal and distal limbs of the
loop were identified and were intact. At this point the resected stomach was placed into a specimen bag and
removed from the right upper quadrant port site. It was closed with an interrupted 0 Vicryl on a Endo Close
device. The other ports were removed under direct vision and the skin sites closed with Monocryl and
Dermabond. The patient tolerated the procedure well. IV fluid was 1800 mL. EBL was 50 mL. Urine output was 500. Anesthesia was provided.

Last edited by nlbarnes; 07-14-2008 at 11:34 AM. Reason: place of service
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