# Exploratory Lap w/removal foreign bodies



## lindacoder (Dec 16, 2013)

DATE OF PROCEDURE:  11/26/13

PREOPERATIVE DIAGNOSIS:  Ingested foreign body.

POSTOPERATIVE DIAGNOSIS:  Same.

PROCEDURE:  Exploratory laparotomy with removal of foreign body x2 and  extensive lysis of adhesions, adhesiolysis time timed at over 2 hours.

 ANESTHESIA:  General.

DRAINS:  Foley, NG.

BLOOD LOSS:  500 mL.   

COMPLICATIONS:  None.

INDICATIONS FOR PROCEDURE:  The patient is status post a foreign body  ingestion of 2 pieces of a razor blade and a key.  This was done in a suicide  attempt.  The patient has a history of mental illness.  He has complained of  severe pain following this.  Despite obvious complications, the patient has  been monitored for 3 days.  The foreign bodies have failed to progress to the  colon.  Because of this, he is brought to the operating room for exploration  and removal of the foreign bodies.

DESCRIPTION:  After the risks, benefits, alternatives, potential complications  were explained in detail to the patient, consent was given.  The patient was  identified, brought to the operative suite and placed supine in the bed.  After adequate anesthesia was obtained, the abdomen was prepped with  chlorhexidine and draped in normal fashion.  A midline incision was made with  a knife.  The patient's previous midline scar from prior surgery was resected.  The subcutaneous tissue was dissected down to the midline fascia with  cautery.  Upon opening the peritoneum, there was obvious significant  adhesions.  An extensive adhesiolysis was performed.  Omental and bowel  adhesions were taken down first from the anterior abdominal wall and then  among the loops of bowel.  The patient had severe adhesions and quite  thickened and chronically inflamed bowel.  The patient essentially had a  hostile abdomen.  We needed to perform a complete adhesiolysis in order to be able to palpate and identify the foreign bodies within the bowel.  With all  limbs of loops of bowel freed up and adhesiolysis complete, I palpated from  the ligament of Treitz distally to the ileocecal valve for the foreign bodies.  Care was taken to avoid real harsh palpation since 2 of these foreign bodies  were razor blade fragments and I did not want to injure myself or the surgical  team.  The patient additionally had a very redundant and large colon.  This  was full of fecal material.  With palpation, I was not able to identify any of  the foreign bodies.  Following this, fluoroscopy was utilized and we were able  to identify a key within the cecum.  Even with identifying this here, it was  quite difficult to palpate but we were eventually able to.  I did have to take  down some lateral peritoneal attachments at the white line of Toldt to  mobilize the cecum up some.  We were then able to identify the foreign body.  This was grasped and pressed up on the surface of the bowel and then a tiny  colotomy made and the key removed.  The colotomy was closed first with an  inner layer of 3-0 PDS and then an outer layer of 3-0 silk Lembert sutures.  Following this, we utilized fluoroscopy to survey the entire small bowel.  I  was able to identify a portion of a razor blade.  This was localized and then  a small enterotomy made into the bowel and the portion of the razor blade  removed.  This enterotomy was closed in layers with a deep layer of 3-0 Vicryl.  This was covered with an outer layer of 3-0 silk Lembert suture.  The  remainder of the bowel was interrogated with the fluoroscopy, and I could not  identify the second piece of razor blade.  One of the preoperative studies had  suggested that this had passed, although this was not definitive.  I once  again palpated the bowel and reinterrogated the entire length of bowel with  fluoroscopy and could not identify any remaining portion of the razor blade.  Because of the question as to whether this passed, and also because of the  risk of palpating the bowel manually with a razor blade in it, we elected to  abandon the search for this piece.  The patient had also had significant OR  time at this point.  Multiple areas of serosal injury to the bowel were closed  with 3-0 silk suture.  There were no frank enterotomies.  There was no  evidence of bowel that appeared devascularized or unhealthy.  With this  complete, the abdomen was irrigated.  Hemostasis was assured.  The fascia was  closed with a looped #1 PDS suture.  The skin was closed with skin staples.  A  gauze dressing was applied.   

The patient tolerated the procedure well.  There were no complications.  All  counts were reported as correct.  He was transferred to recovery room stable.

Looking at possibly expl lap with 22 modifier for extensive lysis of adhesions. Any suggestions are appreciated. 

Thanks


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## koatsj (Dec 16, 2013)

What about 49402? You could try billing 44005 for the adhesions with a -59 modifier or add -22 modifier onto 49402.


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