# Need help with this op note!



## drsbilling (Mar 20, 2013)

Exploratory laparotomy, reducing the stomach from the chest into the abdomen, repair diaphragmatic hernia, creation of a wrap of the fundus around the esophagus and fixation to the stomach underneath the diaphragm.

Heineke-Mikulicz pyloroplasty gastrostomy

After satsifactor induction of anesthesia abdomen was prepared and draped in the usual fashion.  A midline incision was made from the xiphoid to below the umbilicus.  Peritoneal cavity was entered.  The stomac was missing in the abdomen as it was in the chest.  Gradually it was miked down and was able to be reduced completely into the abdomen.  There was a large defect.  The paraesophageal hernia sac was removed.  The crura of the diaphgram were defined by cleaning them of other tissue.  The esophagus was mobilized and encircled with a large Penrose ddrain.  The fundus was mobilized by ligating the vessels on the greater curvature, the spleen was protected.  The vasa brevia were divided between clips and ligatures.  Enough stomach was freed at its junction with the esophagus to produce a wrap around the esophagus, which was then done, brought it posteriorly and then3 sutures of 2-0 silk were put.  The wrap was then also anchored to the diaphgragm underneat it and to the crura.  The crura were then approximated with interrupted sutures of #2 silk approximating the 2 crura.  There was a stricture of the gastric outlet even though was protected the area still it was thought that one should do a pyloroplasty.  Also, because of the stricture which hardly allowed a small finger to go through.  Heineke-Mikulicz pyloroplast was done.  A longitudinal incision was made and it was sutured with #2 silk in a transverse fashion.  A #20 gastrostomy tube was then put in the mid stomach. Two concentric sutures of 2-0 silk were put in , pursestring, and a #20 gastrostomy tube was inserted and brough out through a stab wound.  The site of exit to the stomach was suturued with interuppted sutures of 2-0 silk to completely seal the exit from the stomach to outside.  The abdomen was lavaged.  Jackson-Pratt was put in the left upper quadrant and brought out through a stab wound.  The abdomen was then closed


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## sgochoco (Mar 20, 2013)

This is clearly a repair of a diphragmatic hernia with fundolplasty.   Look at cpt code 43332. The fundolplasty is included in this procedure.


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## sgochoco (Mar 20, 2013)

Forgot..... List the gastroplasty as a seperate procedure.


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## newmanla (Mar 20, 2013)

I agree 43332 and 43800 for the pyloroplasty


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## drsbilling (Mar 21, 2013)

Thanks so much...that one had me confused but when I look at the codes you suggested I agree.  Thanks!


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