# GSW and three different Op reports WOW need Help Please



## bill2doc (Jan 25, 2012)

Please help with CPT codes.  Not sure about all.... ???  Sorry so long.  I will owe someone BIG for this one ;-)

FIRST REPORT:

PREOPERATIVE DIAGNOSIS:  Gunshot the left thoracoabdominal region. 

POSTOPERATIVE DIAGNOSES: 
1.  Gunshot the left upper quadrant of the abdomen.   
2.  Injury to the spleen and left kidney. 

PROCEDURES: 
1.  Exploratory laparotomy. 
2.  Splenectomy with distal pancreatectomy. 
3.  Left nephrectomy.   
4.  Evacuation of the bladder with primary repair. 

ESTIMATED BLOOD LOSS:  3500 mL. 

FLUIDS:  Include 8 units of packed red blood cells, 4 units of FFP, 1 pack of platelets, and 3-1/2 liters of crystalloid. 

SPECIMENS INCLUDE: 
1.  Bullet fragments.   
2.  Spleen. 
3.  Left kidney. 

INDICATIONS:  Gunshot wound to the left thoracoabdominal region.  Gunshot wound in the flank area showed evidence of extruding omentum.  A chest x-ray was performed to rule out a pneumothorax and the patient was then brought to the Operating Room for an emergent exploratory laparotomy. 

DESCRIPTION OF PROCEDURE:  The patient was brought to the Operating Room and placed in the supine position.  The abdomen was then prepped and draped in standard fashion.  A generous midline incision was then made and carried down through the subq fat and fascia.  The fascia was incised after coordinating with anesthesia and the abdomen was then entered.  Of note, there was a significant amount of blood immediately noted upon entry into the abdomen.  The abdomen was then packed tightly in 4 quadrants.   

At this point, the patient became hypotensive.  The patient was allowed to be resuscitated further by anesthesia with volume and blood products.  Once the patient returned to normotension the packs were then evacuated in a systematic manner, beginning in the right upper quadrant, where no injury to the liver or stomach was noted, continuing down to the right lower quadrant where the bowel and right colon appeared to be intact.  The pelvis was notable for a significantly distended bladder.  Of note, preoperatively the patient has been complaining of continuing need to pee and had attempted to urinate.  All that was returned was blood.  A Foley was then placed preoperatively and blood clots were noted, but there did appear to be good flow of urine.  However, at this point the bladder was becoming progressively distended within the pelvis.   

The packs were removed from the left lower quadrant and there is no evidence of ongoing bleeding or hemorrhage from the left colon or sigmoid.  Attention was then focused on the left upper quadrant, where the packs were removed and immediately the patient was noted to have a shattered spleen, which had been partially mobilized by the wound.  The wound appeared to go through the distal aspect of the pancreas.  The splenic artery was palpated near the hilum and hemostasis was achieved by pressure while the kidney was then dissected from the surrounding tissues.  The splenic artery and vein were then clamped as one and suture ligated.  The hilum was then divided.  The spleen and what appeared to be the tail end of the pancreas was then passed off the field as specimen.  Deep to this wound expanding retroperitoneal hematoma was identified.   

Attention turned towards the bullet wound, which was quickly explored.  The left abdominal wall noted a large tissue defect with some exposure of the bone of the 12th rib, but no evidence of diaphragmatic injury as could be immediately assessed.  Attention then turned towards the hematoma, which had been followed and noted to be continued to expand.  The left colon was then mobilized medially by identifying the white line of Toldt and dividing the peritoneal attachments along this plane.  The hematoma appeared to be isolated to the left perinephric area and did not track caudally beyond the bifurcation of the aorta.  The ureter was easily identified during the colonic mobilization and was noted to be dilated and darkened, concerning for blood.  It was at this point that an intraoperative consult was called for Urology and 

The reflected colon allowed identification of the bifurcation of the aorta, which was then tracked proximally and minor periaortic branches were identified, plicated and divided.  The left renal vein was then identified as it crossed the aorta.  It was circumferentially dissected and a vessel loop was then placed around it for control.  There is a small vessel initially superior to the renal vein, which initially was thought to be the renal artery; however, palpation of the posterior and deep aspect of the vein noted a pulsatile artery, which appeared to be more in line with the usual anatomic position.  The previously mentioned vessel was circumferentially dissected and a vessel loop was placed.  The now identified renal artery was also circumferentially dissected.  It was doubly tied using 0 silk on either side of the area of concern and then was sharply divided.  The left renal vein was then divided in a similar fashion.   

The retroperitoneal hematoma was then entered.  The capsule was circumferentially dissected and was also entered.  The hematoma was evacuated as much as was able.  The identified vessel that was still marked with a vessel loop was at this point noted to be the atrial vein, which was similarly tied with 0 silk and divided.  The entire mass was then able to be circumferentially dissected from the surrounding tissue.  The ureter was traced, doubly clipped proximally and distally and then divided.  The kidney was then also passed off the field as specimen.  The abdomen was then copiously irrigated and hemostasis was maintained in the retroperitoneal space.   

At this point, the duodenum could easily be identified.  The aorta was thoroughly examined up to the level of the diaphragm.  There are no other vascular injury was identified.  Attention was then turned towards the bladder, which had expanded considerably.  Stay sutures were placed on either side of the bladder and the bladder was incised and then entered.  There was some urine, but a significant amount of blood clot noted within the bladder.  This was manually evacuated and the bladder was then copiously irrigated.  The bladder was then repaired in 2 layers using 2-0 Vicryl.  The Foley placement was noted to be accurate per intraoperative assessment.  This Foley catheter will need to be a long-term indwelling Foley for at least a week given the bladder repair.   

Attention was then turned towards the retroperitoneal space, which was again examined for any ongoing bleeding.  None was found.  The bowel was then run formally from the ligament of Treitz to the cecum and there is no evidence to indicate injury to the small bowel.  The large bowel was again reexamined.  Of note, the retroperitoneal attachments had been infiltrated by some of the hematoma, which made examination of the colon difficult, but there is no evidence of injury noted.  A #10 flat JP drain was then placed in the pancreatic bed due to assumed leakage, secondary to the distal pancreatectomy.  This JP was brought out through a separate stab incision and then sutured to the skin using 3-0 nylon.  Despite the significant amount of fluid  the patient had received, there is not much remaining edema in the bowel and the patient was therefore able to be closed primarily using #1 looped PDS for the fascial sutures.  Prior to closure the NG tube was verified to be in good position.  The skin was then closed with staples.  The wound packed overnight with Nugauze.  Dressings were then applied.  The patient was then allowed to awaken from anesthesia and brought to the ICU in guarded condition. 

REPORT 2  (five days later)

PREOPERATIVE DIAGNOSIS:  Pancreatic duct leak status post splenectomy with distal pancreatectomy. 

POSTOPERATIVE DIAGNOSIS: 
1.  Pancreatic duct leak status post splenectomy with distal pancreatectomy. 
2.  Multiple areas of infarcted bowel.   
3.  Intraabdominal abscess. 

PROCEDURES: 
1.  Exploratory laparotomy. 
2.  Resection of the distal ileum. 
3.  Extended right hemicolectomy.  
4.  Distal pancreatectomy.  
5.  Abdominal washout. 

SPECIMENS:  Include  
1.  Distal small bowel.  
2.  Right colon. 
3.  Distal pancreas. 

INDICATIONS:  Pt underwent an exploratory laparotomy which resulted in a splenectomy and distal pancreatectomy as well as a left nephrectomy.  Please see the separately dictated operative report for the details of that procedure.  A JP drain was left in place.  Postoperative he remained intubated and appeared to be septic with multiple periodic hypotensive episodes.  He was febrile and was having a significant amount of fluids come out of his JP, which was placed in the pancreatic bed.  The decision was made to return the patient back to the Operating Room to undergo a formal distal pancreatectomy to help control the pancreatic leak.  

DESCRIPTION OF PROCEDURE:  The patient was brought to the Operating Room and placed in the supine position.  A standard timeout was performed, indicating correct patient and procedure.  The abdomen was then prepped and draped in the standard fashion.  The staples from his previous midline incision were removed and the fascial sutures were cut.  The abdomen was then entered.  Of note, there was a significant amount of omentum adhered into the right lower quadrant, and the bowel appeared to be grossly edematous.  The procedure began with running the bowel, which was traced to the distal ileum.  Of note, in this area the bowel was thickened, twisted and stuck in the right lower quadrant.  Once it was manipulated into the wound, it was noted to be quite concerning with multiple areas of necrosis.  The necrosis extended through the terminal ileum, but did not include the cecum.  Decision was then made to perform a small bowel resection including the cecum.  The right colon was then mobilized medially along the white line of Toldt.  The areas of proximal and distal transection were determined.  The small bowel was then divided with a linear cutting stapler.  The mesentery was divided using the LigaSure device and a large mesenteric vessel was identified and suture-ligated.  The right colon was then divided with a linear cutting stapler and the mass was passed off field as specimen.  Examination of the remainder of the small bowel noted no other abnormalities besides diffuse edema.  The colon was examined and followed from the proximal transected region up to the splenic flexure where it was adhered into the previous splenic fossa.  It was then traced along the left colic gutter to the rectum.  Of note, the superior aspect of the entire colon appeared to be intact.  The posterior aspect was then rotated and the colon was examined, and there was an infarcted area right at the splenic flexure with multiple areas of spotty necrosis and what appeared to be a large inflammatory mass in the left upper quadrant.  It is my feeling that this spotty necrosis combined with the fluid from the leak led to a complete breakdown as the wall appeared to be nearly totally transected in that region.  There was a significant amount of inflammatory material.  Given that the left colon up to the splenic flexure appeared to be completely intact circumferentially and had what appeared to be good blood flow, and the right colon had the proximal transection as well as the splenic flexure region, the decision was made to extend the right hemicolectomy to the splenic flexure, leaving a long Hartmann's pouch.  The colon was mobilized in a right-to-left fashion dividing the omental attachments of the lesser sac as well as mobilizing the stomach superiorly and away from the colon.  The mesentery of the colon was divided again using the LigaSure device.  Care was taken to ensure that the vessels of the SMA and SMV were identified and not injured during this process.  The distal aspect of the transsection was identified and divided using a linear cutting stapler.  The transverse colon was then passed off the field as part of the specimen "extended right hemicolectomy."   

The region of the left upper quadrant was more thoroughly examined.  The remainder of the omentum had been significantly dissolved by the inflammatory process.  There is significant amount of rind and what appeared to be the beginning of a left upper quadrant abscess.  The abdomen at this point was copiously irrigated with 6 L of warm sterile normal saline.  The pancreas was then examined at this point.  The exact ductal leak could not be identified.  A formal transection was determined to be appropriate.  The splenic artery was identified and ligated using 0 suture.  The pancreas was then transected using a TA stapler.  The staple line was then oversewn using 3-0 PDS in a running fashion.  The stomach was examined and there was some inflammatory rind in the posterior aspect with some serosal tears, which were repaired in Lembert fashion.  The NG was manipulated into position.  The remainder of the pancreas appeared to be intact and healthy.  The small bowel was again run and examined, and there were no other areas of potential infarct or injury.  The colon and rectum were examined and again no evidence of injury was noted.  Decision was made to leave the divided bowel in place with a long Hartmann's, with plans to bring the patient back for reexploration and a formal ileostomy.  The abdomen was then closed using an intraabdominal wound VAC. 

REPORT 3 (Two days later)

PREOPERATIVE DIAGNOSIS:  Bowel in discontinuity with an open abdomen. 

POSTOPERATIVE DIAGNOSIS:  Bowel in discontinuity with an open abdomen. 

PROCEDURES: 
1.  Reexploration of the abdomen.   
2.  Ileostomy.   
3.  Feeding jejunostomy. 
4.  Replacement of abdominal wound VAC. 

SPECIMENS:  Included the distal small bowel. 

INDICATIONS:  Pt has undergone several previous operations after being shot in the abdomen.  Please see the separately dictated operative reports for the details of those procedures.  His last procedure he was left with an open abdomen.  As he had a significant amount of necrotic bowel, a prolonged operation and a continued need for reexamination, the decision was made to postpone his ileostomy formation.  

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room and placed in the supine position.  His abdomen was prepped and draped.  The abdominal wound VAC was removed.  Of note, there appeared to be bilious staining on the sponge of the wound VAC.  Once the sponge was removed from the abdomen it was thoroughly examined.  The bowel was noted to be significantly edematous.  The distal ileum staple line was not intact.  The mesenteric aspect of the staple line appeared to have dehisced.  There is bilious staining with bowel content contamination throughout the abdomen.  The spillage was controlled using silk sutures to close the leak region.  The abdomen was then copiously irrigated with sterile normal saline.  The abdomen was then again reexplored.  Beginning in the left upper quadrant, there was some purulent drainage with some necrotic debris in the splenic fossa, but the posterior aspect of the stomach as well as the pancreatic stump appeared to be viable with no evidence of ongoing bleeding or injury.  The liver and gallbladder were intact with no evidence of injury.  The left colon was reexamined from the long Hartmann's pouch to the rectum.  There is no evidence of perforation or further infarcted bowel.  The small bowel was then run from the ligament of Treitz to the ileum.  There was fibrinous debris over the entirety of the small bowel, but no further evidence of necrosis or ischemia.  The mesentery was thick and edematous.  The distal aspect of the ileum was examined and a separate skin incision was then made in the right lower quadrant for the stoma.  The circular incision was carried down to the fat through the fascia which was then incised in a cruciate manner.  The rectus muscle was bluntly divided and the distal end was brought through the defect.  The thickened mesentery appeared to be inhibiting blood flow to the exteriorized bowel, and at the demarcationsite, the bowel was again divided and passed off the field as specimen.  Attention was then turned towards the jejunum approximately 40 cm from the ligament of Treitz, the location was determined for the feeding jejunostomy.  The jejunal site was identified using a pursestring suture.  An enterotomy was then performed and the jejunal tube was then advanced.  The tube was then plicated using Witzel-type sutures.  The jejunum was then secured to the wall at the site of entry of the feeding tube.  An attempt was made to close the abdomen; however, the continued swelling from the anasarca made this difficult as he did experience a rise in his peak pressures.  The decision was made to leave the abdomen open and to bring him back in approximately 48 hours to again try to close his abdomen.  Attention was then turned back towards the ileostomy which was then formed in standard Brooke fashion using 3-0 interrupted sutures.  Once the bowel was transected and appeared to be viable, but edematous, the stoma was matured in standard fashion.  The wound VAC was then replaced, and a stoma bag was placed.  A fresh JP was then placed through the previous JP tract and the drain laid out the pancreatic bed.  The wound VAC was then draped in standard fashion.


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