# reduction of the diaphragmatic hernia with open repair resection of splenic flexure



## ksb0211 (Aug 1, 2012)

Hoping for any suggestions.  Just don't want to miss anything.  We don't normally do diaghragmatic hernias.  Also, don't know if it's worth mentioning or not, but this is also documented:
"Of note, the patient has a history of stab wound to the left chest perhaps 7 or 8 years ago which was treated with tube thoracostomy....CT scan was personally reviewed, and he is noted to have a diaphragmatic hernia.  Initially this was thought to be possibly Bochdalek hernia, but after eliciting the history of stab wound, it is clear that this is most likely traumatic in nature.  The colon is within the left chest through the hernia with no evidence of strangulation at this time."
Thanks.

POSTOPERATIVE DIAGNOSIS
Incarcerated diaphragmatic hernia, ischemic colon.

OPERATION PERFORMED
Hand-assisted laparoscopic reduction of the diaphragmatic hernia with open repair resection of splenic flexure of  colon.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR after induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely.

The initial incision was made in the infraumbilical region with a #15 blade and carried down through the subcutaneous tissues.  The Veress needle was introduced.  The abdomen was insufflated to 15 mmHg pressure with CO2.  Once this was done, the 5 mm Optiview port was passed.  It was clear that there was a herniation above the level of the spleen through the diaphragm involving bowel.  Additional 5 mm port was placed in the left rectus muscle.  There were marked adhesions, this actually appeared to be an acute on chronic situation.  The decision was to use the GelPort.  Then, utilizing some laparoscopic assistance, I was able to reduce the hernia.  There were difficulties with ventilation which persisted in spite of completely relieving the insufflation pressure.  Ultimately it was decided to do the procedure open.  On reduction of the colon, it was clear that it was compromised.  The splenic flexure area and left colon was mobilized at the White line of Toldt utilizing the Harmonic scalpel.  The diaphragmatic hernia was then closed utilizing interrupted 0 silk suture.  It appeared to be adequate closure.  With this completed, the resection was performed of the splenic flexure of the colon.  The GIA stapling device was fired x2.  The bowel clamps were applied.  The bowel was then reapproximated with interrupted 3-0 silk suture, a functional end-to-end anastomosis performed with a GIA green.  The enterotomy was closed with the TA 60 green.  With this completed, the rent in the mesentery was closed with running 2-0 Vicryl.  The bowel was returned to the abdominal cavity.  The abdominal cavity was irrigated with antibiotic solution and the left upper quadrant appeared to be free air or free of any bleeding.  The midline incision was closed with #1 PDS suture and closed with clips.  Once this was completed, the patient was reprepped and draped for a chest tube insertion.  A 32 chest tube was then inserted at approximately the 7th interspace mid axillary line.  It was secured with 0 silk suture.  Chest x-ray ordered postprocedure.  Dressings were applied.  The patient tolerated the procedure.  Estimated blood loss, perhaps 250 mL.


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## cmartin (Aug 9, 2012)

39541, 44140 & 44139. Add V64.41 to your other dx codes for laparoscopic procedure converted to open. I'm not sure whether the chest tube is billable w/the diaphragmatic hernia repair or not, if so I think it's 32551 now but you'd better double check that. 552.3, 557.9, 908.0, V64.41 - not in that order but I think those are your dx codes. 
May need some fine-tuning but i think that's ball-park.


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