# Exploratory Lap, resection of duodenum



## bill2doc (Jan 12, 2012)

Can anyone help with the correct CPT code for this procedure?  I thinking 49000 but not sure if that covers everything and if I'm even close.... Pls advise. Thank you

PREOPERATIVE DIAGNOSIS:  Upper GI bleed. 

POSTOPERATIVE DIAGNOSIS:  Upper GI bleed. 

PROCEDURE:   
1.  Exploratory laparotomy. 
2.  Resection of the third and fourth portions of the duodenum. 
3.  Duodenoscopy.   
4.  Primary duodenal jejunal anastomosis.  
5.  Placement of feeding gastrojejunostomy.  

ESTIMATED BLOOD LOSS:  1500 mL.   

IV FLUIDS:  Include 1400 mL of normal saline, 7 units of packed red blood cells, 2 platelet phoresis packs, 4 units of FFP.   

SPECIMENS:  Included the distal duodenum.  

SPONGE AND NEEDLE COUNTS:  Correct.   

CONDITION:  Critical.   

COMPLICATIONS:  Superior mesenteric vein injury.  

INDICATIONS:   After review by the GI consultant, a push enteroscopy was performed with the intent of identifying the likely culprit of her upper GI bleed, which was vascular ectasias.  There were numerous small ectasias noted but none of them appeared to be the source of her acute bleed.  She continued to not improve and, in fact, she began to need both pressors as well as blood.  It was at this point, that given her multiple failed attempts at therapeutic localization studies that decision was made to resect distal duodenum, where the bleeding had been identified.  I spoke with both the patient. The risks, alternatives, and benefits of the procedure were discussed, including but not limited to bleeding, infection, injury to the bowel, complications of anesthesia and the real potential for death.  The patient voiced understanding and a surgical consent was signed.   

PROCEDURE:  The patient was brought to the operating room and placed in a supine position.  A standard timeout was performed, identifying the preparation and correct procedure.  The patient was then endotracheally intubated.  The abdomen was prepped and draped in sterile fashion.  An upper midline incision was then made and carried through the subcutaneous fat to reveal the fascia, which was then incised to the midline.  Examination of the abdomen; noted is a significant amount of omental adhesions into the lower quadrants and black fluid throughout the small bowel. The exploration began in the right upper quadrant, where the duodenum was mobilized with a generous Kocher maneuver.  The thickened ligament of Treitz was incised and the overlying peritoneum was dissected free.  The feeding vessels to the duodenum at this point were serially ligated.  The proximal most jejunum was then divided with a linear cutting stapler.  The mesentery was divided with the LigaSure device.  The lesser sac within the proximal duodenum was then exposed.  The ligament of Treitz was then approached from the retrocolic position.  It was at this point that during this active formation of the tunnel, that the superior mesenteric vein was then identified but noted to be injured along a lateral side branch.  This wound was repaired using interrupted 4-0 Prolene.  Hemostasis was then achieved.  The tunneling progressed and the duodenum and the pancreas were localized more medially as was the distal duodenum and jejunum.  At this point, the proximal most jejunum was then divided with a linear cutting stapler and the distal duodenum was then passed through the ligament of Treitz into the lesser sacs space.  The remainder of the perforating branches into the duodenum were then divided.  The flexible cystoscope was then brought onto the field and attached to the camera.  The duodenum was then elevated and a pursestring suture of 3-0 Silk was then placed.  The bowel was then incised and the cystoscope was then advanced into the duodenum.  The scope was passed proximally and the ampulla of Vater was not identified.  However, the multiple ectatic lesions were noted in the mucosa of the duodenum.  Again, no single site seemed to be the source of the overall bleeding, however, they all had a continuous ooze.  The duodenum was then divided with a linear cutting stapler at the juncture of the second and third portions and passed off field as specimen.  Attention was then returned to the proximal jejunum.  The peritoneum of the mesentery was incised to allow for better mobility and mobilization.  The jejunum was then passed, through the tunnel formed by the ligament of Treitz, and then brought to the second portion of the duodenum.  The handsewn side to side anastomosis was performed in the standard 2 layer format, using 3-0 Vicryl and Silk.  The patient prior to this operation had a PEG tube for her enteral feeds.  This has been removed during the bowel prep.  A 14 F gastrojejunostomy tube was then passed through the skin into the stomach after efficacy of the balloon was verified.  The tube was then manually placed beyond the anastomosis.  The balloon was inflated and the tube was sewn in place, using interrupted 3-0 Nylon.  The defect in the colonic mesentery was then closed, using a running 3-0 Vicryl.  At this point the abdomen was copiously irrigated with sterile normal saline.  The fascia was then reapproximated, using loooped #1 PDS suture in a running fashion.  Due to the length of the case, the amount of blood loss and the patient's body habitus, an x-ray was then taken of the patient's abdomen to rule out any missing lap sponges.  None were noted upon review by myself.  Skin was then able to be closed, using staples.  Dressings were then applied.  The patient was then brought to the ICU in critical condition.


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## RonMcK3 (Jan 12, 2012)

*I'd look in Digestive System > Intestines (except Rectum)*

It appears to me that you have:

44120 Enterectomy, resection of small intestine, single resection and anastomosis
and

+44015 Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (list separately in addition to primary procedure)


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## cmartin (Jan 16, 2012)

I agree


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