# Laparoscopic drainage pelvic and subhepatic abscess/placement JJ feeding tube



## Trendale

Hello,
Please help with the following op report:
49441?/49323/49329???

REOPERATIVE DIAGNOSES:
1    Sepsis.
2    Fever.
POSTOPERATIVE DIAGNOSIS:  Multiple intra-abdominal abscesses.
NAME OF OPERATION:
1    Laparoscopic drainage of pelvic and subhepatic abscesses.
2    Placement of jejunostomy feeding tube.
ANESTHESIA:  General anesthesia with intubation.
ESTIMATED BLOOD LOSS:  About 10 cc.
INDICATIONS FOR THE PROCEDURE:  The patient is a 43-year-old white
male who underwent a Roux-en-Y gastric bypass on July 15.  He
developed a leak and was taken back to the operating room for
re-exploration and <Graham> patch.  He has been doing well in the ICU.
In the last 48 hours was still spiking temperature and a CT obtained.
It showed some collection in the subhepatic region and the pelvis
region.  A decision was to make take him back to the operating room.
GROSS OPERATIVE FINDINGS:  The patient had a large abscess collection,
subphrenic, subhepatic region, containing some purulent material.  The
area of the previous leak at the gastrojejunostomy had actually sealed
and did not show any pathology.  He also had a large abscess in the
pelvis that was easily drained as well.
DESCRIPTION OF OPERATION:  The patient was brought to the operating
room, positioned on operating table in supine fashion.  The patient
already had been intubated in the ICU.  The abdomen was prepped and
draped in the usual sterile fashion.  One of the small laparoscopic
incisions in the right upper quadrant was reopened and blunt digital
dissection was used to enter the abdomen, and a trocar was placed in
the abdomen.  Abdomen insufflated with CO2 to 15 mmHg.  Immediately
under direct laparoscopic vision, we placed another 12 mm port in a
midabdominal incision about 8 cm from the xiphoid, and we placed
another 12 mm port in the left upper quadrant subcostal mid clavicular
line, a previous site as well.  An additional 5 mm port was placed in
the left upper quadrant subcostal mid axillary line.  Immediately,
using the suction irrigator, we immediately began exploring the area
of leak where we had a previous patch.  This area had healed without
any problems and without any further evidence of leaking.  We now
removed the old drains and noticed some purulent drainage coming out
from a subhepatic subphrenic position.  There, we entered an abscess
collection which had some purulent material in it.  We used about 3 L
of antibiotic solution to completely drain the peritoneal cavity,
including the subhepatic abscess.  We left a 19 French round Blake
drain to drain this area, and then we concentrated in the area of the
pelvis.
In the pelvis as well, we found some fluid collection in the right
side of the pelvis.  It contained some purulent material as well as
old hemolyzed blood.  Again, we irrigated the area until we completely
cleansed the area and left another 19 French Blake round drain to
drain the area as well.  Next, 2-0 silk was used to hold these drains
in place.  After the drain had been placed appropriately, the upper
drain that was draining the subhepatic abscess was placed so that it
will actually also drain the area of the gastrojejunostomy, although
we did not see any further leaks, and the patch had sealed the
previous leak.  Upon finishing irrigating the abdomen, again about 2 L
of antibiotic solution were used.
We now placed a feeding jejunostomy tube.  We chose an 18 French
T-tube.  It was cut to size.  We used an 0 silk and put a pursestring
on the Roux limb about 10 to 12 cm from where ??<__________>.  A small
enterotomy was made.  The T-tube was placed inside the abdominal
cavity through one of the trocars and placed inside the Roux limb.
The pursestring was now tied, and the same silk was now used to bring
it up towards the anterior abdominal wall using this as a suture
passer.  We probed both <limbs> of the sutures and tied it to the
abdominal wall.  All silk times 2 were now used to attach it to the
skin.  At this time, the abdomen was deflated and a closure performed.
Closure of  the laparoscopic incision was done with 4-0 Monocryl in
subcuticular fashion, followed by Benzoin and Steri-Strips.  Patient
tolerated the procedure quite well and was taken back to the ICU in
stable condition.


Thanks in advance!


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## Trendale

*Reply-best cpt codes*

The most accurate I used:
49322 and 44300


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## AnnaMoris

*subhepatic abscess*

How would you code for an open procedure of drainage of subhepatic abscess due to post op wound infection?


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