# Diag Lap converted to Open w/ internal hernia



## bill2doc (Sep 10, 2012)

Looking for help on both the initial and the follow up procedure. Can anyone help with CPTs and simple explination... Thank you so much!

POSTOPERATIVE DIAGNOSIS:  Small-bowel obstruction secondary to internal hernia.

1.  Diagnostic laparoscopy.
2.  Conversion to exploratory laparotomy.
3.  Reduction of internal hernia with lysis of adhesions.

PROCEDURE:  A curvilinear infraumbilical incision was made and carried through subcutaneous tissue to the fascia at the base of the umbilicus.  A fascial incision was then made.  A heavy Vicryl was placed on either side of the fascial defect.  The Hasson trocar was then entered in the abdomen and pneumoperitoneum was established.  Examination of the abdomen noted a significant amount of serosanguineous ascites fluid over the dome of the liver as well as the bilateral pericolic gutters.  In the left upper quadrant there was purple edematous bowel concerning for ischemia.  Given there is no obvious indication as the cause for this event, the procedure was then converted to open to do a full exploration.  The pneumoperitoneum was allowed to resolve and a midline incision was then made and carried through subcutaneous tissues to the fascia.  The ascites fluid was then evacuated and totaled approximately a liter.  The bowel was then run from ligament of Treitz to the ileocecal valve.  There was edematous thickened purple bowel that was eviscerated and evaluated.  The mesentery was examined.  There were omental adhesions that extended from the omentum to the left lower quadrant.  These were released, they had formed a tight band across the base of the mesentery at this point and the patient had essentially developed an internal hernia at this point.  The demarcated bowel was measured.  It was approximately 125 cm in length.  The distal aspect appeared to be approximately 70-75 cm from the ileocecal junction.  Exploration of the remainder of the abdomen was essentially benign.  The NG tube was noted to be in good position.  There are no lesions noted in the liver or spleen.  The colon appeared to be intact.  The gallbladder noted no evidence of acute inflammation.  Attention then returned to the injured segment of bowel.  The bowel appeared to be pinking up satisfactorily and there appeared to be consistent evidence of peristalsis throughout.  The bowel was wrapped in a warm, moist towel and subsequently reexamined after approximately 10 minutes and this pinking effect continued to improve.  There was still a demarcation across the mesentery, but good evidence of continuous blood flow to this segment of bowel once the obstruction had been released.  The decision was then made at this point to abstain from a bowel resection at this time given the size of the injured segment and this bowel appeared to be viable and showed no evidence of sloughing or gross infarction.  The plan was then made at this point to perform a second look operation within 24 hours to reevaluate.  The abdomen was again explored from the pelvis where the uterus was noted to be normal with 2 normal ovaries to the colon and the remainder of the abdominal organs.  Again, no other lesions were noted.  The omentum was reexamined to determine whether there were other potential hernia sites which were divided.  The abdomen was then closed using just simple closure of the skin. Dressings were then applied.  

PROCEDURE THE NEXT DAY
Ischemic bowel secondary to internal hernia.

1.  Reexploration laparotomy.
2.  Fascial closure.

DESCRIPTION OF PROCEDURE: The sutures from the previous midline incision were removed.  The abdomen was then opened and explored in a surgical fashion.  The bowel was run from the ligament of Treitz to the ileocecal junction and the area of concern still showed evidence of delineation, all of which were improving.  The color of the bowel changed from purple to pink.  There was no evidence of focal necrosis or gangrene and there appeared to be peristalsis throughout the bowel, including this segment.  The colon was examined as well and there is no evidence of lesions.  The remainder of abdominal organs were also inspected and noted to be without injury.  There is no evidence of ongoing hemorrhage.  The bowel was determined to be reliably viable at this point and the decision was made to proceed with fascial closure without resection.  The fascia was then closed. The skin was closed with staples.  Dressings were applied.


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## Robin R (Sep 14, 2012)

Day 1, I would code 44050 for the internal hernia reduction.  Don't forget to include in your dx the V code for "laparoscopic surgical procedure converted to open" (V64.41)

Day 2, since he's just inspecting & doing nothing else, I would code 49002 (reopening of recent laparotomy).  Use modifier 58 if this was a planned trip to the OR or 78 if unplanned.


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