# Diag lap, expl laparotomy, pexy of the stomach to anterior abd wall, stryker irrigatn



## ksb0211 (Jan 12, 2012)

Okay, this one is completely new to me.  Hoping for some direction.  I've never had to bill a "pexy of the stomach to abdominal wall" and I don't want to miss anything.  
Thank you so much.

POSTOPERATIVE DIAGNOSIS
Peritonitis, pneumoperitoneum secondary to the leaking gastrostomy tube.

OPERATION PERFORMED
1.  Diagnostic laparoscopy, exploratory laparotomy, pexy of the stomach to anterior abdominal wall, Stryker irrigation of abdomen.

INDICATIONS
The patient is a 62-year-old female with a history of multiple medical issues.  The patient was admitted with evidence of dehiscence of the right above-knee amputation stump.  The patient has renal failure and sepsis.  A PEG tube had been placed 3 days ago.

Chest x-ray revealed free air.  CT scan showed increased fluid and air within the peritoneal cavity.  Concern that some of the tube feeding may of extravasated enough to warrant at least laparoscopy.  The patient was therefore submitted for laparoscopy, possible exploratory laparotomy.  This was discussed in detail with the family.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR, after induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely.  The skin was incised in the right upper quadrant with a #15 blade.  The Optiview port was passed without difficulty.  Immediately upon entering the peritoneal cavity, a green murky fluid was noted.  Cultures were taken.  The fluid was coming through the ports.  I was able to insufflate and see that it was safe to enter the peritoneal cavity in the midline.  An incision was made, it was clear that this could not be handled well laparoscopically.  The midline incision was utilized.  The omental adhesions were taken down.  A thick coating was appreciated over much of the liver, peritoneum and bowel.  The Stryker irrigator was utilized and all pockets were opened.  Approximately 5 L of irrigation fluid were utilized.  What appeared to be nonviable omentum was resected and passed off.  The gastrostomy tube passed through omentum and into the stomach.  The tube was a Ponsky PEG tube and therefore was left in place and it was secured with a pursestring of 2-0 silk.  This was then tacked to the anterior abdominal wall with additional 2-0 silk sutures.  The bolster was tightened to keep the stomach in close opposition to the abdominal wall.  Once this was completed, 10 mm Jackson-Pratt drains were placed via the laparoscopy site in a separate stab incision.  The midline incision was closed with running double stranded #1 PDS suture.  Retention sutures were placed.  The wound was not closed.  A bulky dressing was applied.  The patient tolerated the procedure, but remains somewhat hypotensive with a systolic pressure of approximately 80.  She will remain on the ventilator.


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## ksb0211 (Jan 31, 2012)

This report is really bothering me.  There doesn't seem to be anyone who can figure this out.  LOL
I know that the laparoscopy/laparotimy is going to be bundled into whatever else is billed.  I'm just wondering if there is anything other than an unlisted code.  
If you even had a suggestion, I would be so appreciative.  Thanks.


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## Lujanwj (Feb 1, 2012)

Maybe 49255-22.  -22 for the pexy or 43830 (-52/22 depending on work value) or 43999.  I'm leaning towards 49255-22 (secondary DX V64.41) but....

Good Luck!


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