# Small Bowel Resection with Roux-en-y Reconstruction



## ch81059 (Oct 2, 2014)

Hi Everyone,

I have an operative report on a patient that had a small bowel resection due to gangrene secondary to a Peterson's hernia.  The patient had the small bowel resection and in addition had a Roux-en-y reconstruction because she previously had a gastric bypass. I believe the appropriate codes would be 43848 for the roux-en-y reconstruction and 44120 for the small bowel resection.  Could you please take a look at my operative report and give me your opinions?  Thanks so much.

OPERATIVE REPORT

Date of Service: 07/23/2014

PREOPERATIVE DIAGNOSIS
Probable gangrene of small bowel secondary to internal hernia.

POSTOPERATIVE DIAGNOSIS
Gangrenous small bowel secondary to Peterson's hernia.

ANESTHESIA
General.

PROCEDURE
Laparotomy with small-bowel resection, and a Roux-en-Y reconstruction.

ESTIMATED BLOOD LOSS
150 mL.

COMPLICATION
None.

DRAINS
None.

PREOPERATIVE EVALUATION
is 36 years old and presented to the emergency room at *xxxxxxxxxxx* on the evening of July 21, 2014. She was profoundly septic, was admitted to the Critical Care Medicine Service. She has a history of being recently incarcerated and also of IV drug use. She was felt to be septic related to her
intravenous drug use, however, when she improved and was extubated, it
became apparent that she had a previous gastric bypass, and she was
complaining of some rather significant abdominal pain. CT scan was done, which showed findings compatible with an internal hernia, with
small bowel obstruction and possible gangrenous bowel. She was,
therefore, taken to the operating room under an urgent basis for
exploratory laparotomy.

PROCEDURE IN DETAIL
After adequate premedication administration of appropriate preoperative
antibiotics and DVT prophylaxis, the patient was taken to the operating room, where general anesthetic by way of endotracheal intubation, was
carried out by the anesthesia department. The patient had sequential
compression devices placed on her lower extremity. A Foley catheter was
already in place. Her abdomen was prepped and draped in a sterile
fashion. A midline incision was made from the xiphoid down to below the
umbilicus. It was carried down through the skin and subcutaneous tissue
and hemostasis was obtained with electrocautery. The abdominal cavity was entered. There was a copious amount of cloudy peritoneal fluid.  The small bowel was massively distended and there was obvious gangrenous small bowel. After exploring the abdomen, it became apparent that the patient had a Peterson's hernia and had gangrene of the small bowel extending from her ligament of Treitz down to her jejunojejunostomy.  This was resected by dividing the healthy ends between the 75 mm linear cutters. The mesentery of the small bowel was taken down using the LigaSure device and the specimen was removed from the operative field.  There was only a small amount of duodenum just beyond the ligament of Treitz, but I was able to get a pursestring suture around this and a 25- mm anvil was placed into this bowel and the pursestring suture was tied down. We then brought the previously transected small bowel up to this area. An enterotomy was made and the stapling device was placed through the enterotomy and an end-to-side anastomosis was carried out. The opening for the stapling device was closed using a 60-mm linear stapler.  We then re-did the jejunojejunostomy by taking the Roux limb, and creating an enterotomy in this and placing a 28-mm stapler through this and the antimesenteric border of the small bowel was grasped, a pursestring suture was placed and the anvil was placed into the small bowel at its antimesenteric border. The instruments were put together to fire and creating a 28 mm jejunojejunostomy. The open end of the Roux limb was then closed using the 60-mm linear stapler. The stomachhad been previously decompressed and suctioned of several liters of
fluid and a PEG-type Ponsky gastrostomy tube was placed into the stomach, held in place with a 2-0 silk pursestring and was brought out through a stab wound in the right upper quadrant and secured to the abdominal wall using the supplied bolster. The jejunostomy tube was placed about 20 cm distal to the jejunojejunostomy by placing a pursestring suture in the antimesenteric border of the small bowel. The bowel was opened and a 2nd Ponsky-type tube was placed into the small bowel and brought through a stab wound in the abdominal wall to the left had been previously decompressed and suctioned of several liters of fluid and a PEG-type Ponsky gastrostomy tube was placed into the stomach, held in place with a 2-0 silk pursestring and was brought out through a stab wound in the right upper quadrant and secured to the abdominal wall using the supplied bolster. The jejunostomy tube was placed about 20 cm distal to the jejunojejunostomy by placing a
pursestring suture in the antimesenteric border of the small bowel. The
bowel was opened and a 2nd Ponsky-type tube was placed into the small
bowel and brought through a stab wound in the abdominal wall to the left of the midline, and it was again secured to the anterior abdominal wall using the supplied bolster. The abdomen was copiously irrigated. The fascia was closed with a running looped PDS suture. Skin was closed with skin staples. The patient remained hemodynamically stable throughout the procedure and returned to the intensive care unit with relatively stable vital signs.

Any help would be greatly appreciated!


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## ch81059 (Oct 3, 2014)

Thoughts, suggestions, opinions?  Anybody?


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