# Total Pancreatectomy



## monbel (Aug 17, 2011)

My surgeon performed a total pancreatectomy along with a hepaticojejunostomy (extra hepatic); duodenojejunostomy, splenectomy and choleystectomy.  My question is do I bill for all of these separately with 48155?


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## surgonc87 (Aug 17, 2011)

I have a few ideas, can you post the op note though.
MS


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## monbel (Aug 18, 2011)

Here you go...appreciate you taking a look!


Thompson retractor was placed on the bed and used to retract the wound edges. The pancreas was examined by opening the gastrocolic ligament.  This was done with the LigaSure.  This was done from the right gastroepiploic vessels up to the short gastric vessels.  This allowed the pancreas to be examined.  The head  of the pancreas was examined by doing Kocher maneuver.  This demonstrated  multiple lesions throughout the pancreas.  The remaining short gastric  vessels were taken down to the superior border of the spleen using LigaSure.   The gastrocolic ligament was taken down to the level of the duodenum.  This  allowed the duodenum and head of the pancreas to be fully mobilized and  allowed identification of superior mesenteric vein.  This was dissected free  beneath the neck of the pancreas opening a tunnel to the superior border of  the pancreas.  An umbilical tape was placed in this space.

The mass in the head of the pancreas was biopsied using a Tru-Cut biopsy  needle. Frozen section was returned as cells consistent with neuroendocrine  tumor. Electrocautery was used for hemostasis at the biopsy site.   Based upon examination of the pancreas, it appeared that total pancreatectomy  was appropriate for resection of all of these masses.

The pancreas was freed up by incising the peritoneum along the superior and inferior borders of the pancreas.  This allowed the pancreas to be completely surrounded by  dissection in the avascular retroperitoneal space.  This allowed identification of the splenic  artery just after its origin from the celiac axis.  It was dissected free and surrounded with a vessel loop.  The splenic vein prior to  its junction with the superior mesenteric vein was treated in a similar  fashion.  The splenic artery was doubly ligated with #2-0 silk ties and  a #4-0 Prolene suture ligature on the patient's side and divided.  The  splenic vein was doubly ligated with #2-0 silk ties and #4-0 silk suture  ligature on the superior mesenteric vein side and divided.  The pancreas was  elevated out of the retroperitoneal space using blunt and cautery dissection.   This was done to the splenic hilum.  The spleen was mobilized by  incising its peritoneal attachments.  This allowed the entire specimen including the  Spleen, body and tail of the pancreas to be elevated anteriorly and medially.  Because he had a large bulky spleen, a clamp was placed across the vessels in the splenic hilum and the spleen was removed.  The vessels were  ligated with #2-0 silk ties.  The dissection was taken up to the level of the  superior mesenteric vein and portal vein.

A cholecystectomy was then done.  The gallbladder was taken down to the gallbladder fossa using electrocautery to incise the peritoneum and the  adventitia immediately adjacent to the gallbladder.  This was done down to  the level of the triangle of Calot.  The cystic artery was identified, doubly  ligated with #2-0 silk ties and divided.  The cystic duct was treated in a  similar fashion.  The gallbladder was removed and sent to pathology.

The hilar dissection was done with the bile duct being dissected free just  proximal to its junction with the cystic duct.  It was ligated at this site  and divided.  All soft tissue in the porta hepatis was dissected off the  hepatic arteries and the portal vein and stripped inferiorly and maintained  with the specimen.  This included the celiac axis, soft tissue around this  splenic artery, common hepatic artery, and the portal vein.  This allowed  Identification of the common hepatic artery and gastroduodenal artery.  The  gastroduodenal artery was dissected free and occluded with a vascular clamp.   There were good pulsations distally in the right and left hepatic arteries. The gastroduodenal artery was then doubly ligated with 2-0 silk ties and a 4-0 Prolene suture ligature on the patient's side and divided.  This allowed  the pancreas and all soft tissues to be dissected free from the  hepatoduodenal ligament in the porta hepatis.

The lower abdomen was  entered and the proximal jejunum past the ligament of Treitz was  identified.  The bowel was divided with the GIA stapler.  The mesentery was  taken down with the LigaSure up to the level of the ligament of Treitz.  The ligament of Treitz was incised and opened and this allowed delivery of the duodenum and  proximal jejunum beneath the mesenteric vessels into the right upper  quadrant.  The pancreas was dissected off the superior mesenteric vein, portal vein, and superior mesenteric artery using the blunt, cautery, and  sharp dissection.  The tissue was divided with the LigaSure or between #2-0  silk ties and divided between the ties.  This removal of the specimen. It was taken to pathology by me and oriented later in the  procedure.

The operative sites were irrigated and inspected and hemostasis was present.

The proximal jejunum was brought up through a transverse mesocolon defect  into the right upper quadrant.  The staple line was oversewn with 3-0  Vicryl sutures in a Lembert fashion.  The hepaticojejunostomy was constructed  to an anti-mesenteric jejunotomy.  The mucosa was tacked to the serosa using 6-0 PDS sutures.  The anastomosis was constructed with interrupted 5-0  PDS sutures.  The site was irrigated and a clean sponge was placed around it.   The jejunum as it passed through the transverse mesocolon was tacked to the  transverse mesocolon with interrupted 3-0 Vicryl sutures.  Further  downstream, a loop of jejunum was identified and brought up in an antecolic  fashion.  The duodenojejunostomy was constructed in 2 layers.  The outer  layer was interrupted 3-0 Vicryl sutures in a seromuscular fashion.  The staple  line was excised from the duodenum and the inner layer was constructed with  running 3-0 Vicryl suture.  The anterior row was done in a Connell fashion.   The remaining exterior layer was done in a Lembert fashion with 3-0 Vicryl.  There was a palpably patent anastomosis at the end of the  construction.

The operative sites were irrigated and inspected.  Hemostasis was present.   The viscera were placed back in their normal anatomic position.  The wound was closed by approximating the fascia with running #1 PDS suture.  The wound was irrigated and dried.  The skin edges were approximated with skin clips.


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## surgonc87 (Aug 19, 2011)

47780 vs 47760 
48155-m-51
47600-m-51
48100-m-58 ( intraoperative frozen section which ensued the total removal)

MS


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## monbel (Aug 19, 2011)

thanks so much that was what I had written down as well. Just needed to make sure I was dong the right thing.


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