# CPT for Laparoscopic distal pancreatectomy



## s.greene.cpc

Please help. Need CPT for Laparoscopic spleen preserving distal pancreatectomy. I'm thinking unlisted 48999?  Why..Why..isn't there a code for this?


OPERATIVE PROCEDURE:  After informed consent was reviewed she was taken
back to the Operating Room.  She was placed in a supine position.
Sequential compression devices and perioperative antibiotics were
administered, followed by a general endotracheal anesthetic.  She was then
placed in the low lithotomy position and prepped and draped in the usual
sterile fashion.  Local anesthesia was infiltrated in the subcutaneous
tissues beneath her umbilicus.  A linear incision was created extending
into the umbilicus using a #11 blade.  Blunt dissection was used to carry
down to the level of the abdominal fascia.  The fascia was incised in the
midline using a #11 blade, and a figure-of-eight 0 Vicryl suture placed
there.  A Hasson trocar was inserted.  Pneumoperitoneum was achieved using
standard CO2 insufflation techniques.  I then placed the patient in steep
reverse Trendelenburg position.  Under direct endoscopic surveillance I
placed additional trocars in standard positioning for laparoscopic
pancreatic surgery.

The operation began by dividing the gastrocolic ligament and entering the
lesser sac by dividing this below the gastroepiploic vessels.  This
division was continued along the length of the greater curvature of the
stomach, widely exposing the pancreatic tail.  A Nathanson liver retractor
was inserted for anterior retraction of the stomach.  We began the
operation by incising the peritoneum on the inferior aspect of the
pancreas.  Carefully this was continued distally, and we then developed a
plane in the retropancreatic space using an EnSeal device to seal any
encountered retroperitoneal small vessels.  Once an adequate space was
created we then divided the peritoneum overlying the cephalad surface of
the pancreas and began developing this space in an attempt to join the 2
spaces.  The splenic artery was encountered initially, and this was
carefully dissected distally, freeing up a sizable segment of the splenic
artery.  We then encountered the splenic vein and circumferentially
mobilized it as well.  It was approached best from the posterior surface of
the pancreas.  Once the pancreas was able to be retracted well anteriorly,
we began our more thorough retropancreatic dissection continuing distally.
We inserted a laparoscopic ultrasound probe, and we were able to identify
the position of the cyst.  We developed a plane proximally in the pancreas
to accommodate a laparoscopic GIA stapling device.  We divided the pancreas
at the distal body just proximal to the position of the cyst seen on
ultrasound.  A vascular cartridge was used as well as seam guard, and I was
able to insert a 2-0 Prolene stitch at the inferior border of the pancreas
to control its marginal vessel.  The staple line was completely hemostatic.
We then carefully undertook the dissection of the splenic vein which was
densely adherent to the pancreas gland at its anterior border.  Judicious
use of the electrocautery was used as well as blunt traction, counter
traction, carefully mobilizing the splenic vein inferiorly.  Some bleeding
was encountered at one point that was controlled with a 3-0 Prolene stitch.
Very happy with hemostasis at this point, we continued this dissection
distally.  Blood loss at this point was about 175 mL.  We were able to
completely mobilize the pancreas gland away from the splenic vein and
divided it with the EnSeal device just beyond its distal portion.  Again
great care was taken to avoid injury to the splenic vessels, and we ensured
a complete resection of the distal pancreas.  It was placed in an EndoCatch
bag and delivered through the periumbilical trocar site.  It was sent to
Pathology for examination.  The frozen section analysis determined it to be
a benign lesion, and at this point we reviewed the abdomen for additional
bleeding.  The operative field appeared to be hemostatic.  I did use
Tisseel over the proximal pancreatic staple line and in the area of
dissection of the splenic vessels.  A drain was placed just beside the
pancreatic staple line, and this was exteriorized to the far lateral trocar
site.  Trocars and the Nathanson liver retractor were removed under direct
endoscopic surveillance.  The fascia at the umbilicus was closed using the
previously 0 Vicryl suture and an additional 0 Vicryl figure-of-eight
stitch.  Skin incisions were closed with Monocryl suture and topical skin
adhesives.

The patient tolerated the procedure very well.  She was transported back to
the Recovery Room in suitable condition.

This operation took approximately 5 hours and required the use of two
general surgeons as well as advanced laparoscopic expertise.


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## jaimewicklund

One of my docs does this same procedure, and we will out 48999, with the equivilant open being 48140. We rarely have issues getting reimbursed, however it always requires us to drop the op note to the insurance company. Good Luck!!


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## s.greene.cpc

Thanks so much


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## yhinton

Hello,

I hvae a request for a laparoscopic partial pancreatectomy, splenectomy and I can't seem to find a specific code. usually, I use the laparoscopic unlisted code but the only code listed is unlisted procedure pancreas which is an open code. please help!


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