# Exp Lap, Omentectomy, Appendectomy, washout



## bill2doc (Sep 10, 2012)

I was thinking 49255 w/ 44955 but not sure if thats correct.  Also don't see a wash out code ???  Help pls !!

POSTOPERATIVE DIAGNOSIS:  Secondary bacterial peritonitis.

1.  Exploratory laparotomy.
2.  Omentectomy.
3.  Appendectomy
4.  Abdominal washout.


had a history of cirrhosis that had been previously noted to have no complications and had recently undergone a tubal ligation on the 3rd of August.

PROCEDURE:  A midline incision was made and carried through subcutaneous tissue to the fascia.  Entry into the abdomen, noted significant amount of crusty brown ascites fluid noted.  Half of this was aspirated and sent for culture.  The incision was then extended and ascites was removed from all 4 quadrants.  Upon immediate examination, there was a thickened inflamed omentum that was sucked down into the pelvis and as the 4 quadrants of the abdomen were examined, there were multiple pockets of frank pus.  Second culture specimen was sent.  There was rind and fibrinous material along the bilateral paracolic gutters, which appeared consistent with potential for an occult perforation.  Examination began in the left lower quadrant.  The omentum was dissected from the anterior wall of the pelvis and reflected laterally.  The small bowel itself appeared to be a whole and uninjured, although it had multiple segments with significant amount of inflammatory rind and localized pockets of pus.  The bowel was then run from the ligament of Treitz to the ileocecal junction.  There were several small serosal tears that were encountered and were repaired.  The colon was then examined.  The cecum was inflamed and with a plastered rind that appeared distinct from the white line of Toldt.  This rind was divided along the right pericolic gutter.  The cecum was quite socked in and a ball of terminal ileum and cecum were gently dissected away from each other.  The appendix was at the center of this ball during the dissection.  The mesoappendix was divided.  It did not appear that the appendix was the source of this inflammation, although there was a significant amount and as the mesoappendix had already been taken, the appendix was then divided across its base with a linear cutting stapler and passed off the field as specimen.  It was at this point that the patient's ascitic fluid appeared to become significantly bloody.  She had an initial INR of 1.4, but had extensive portal hypertension and the sequelae of such.  The omental veins were significantly enlarged and under high pressure, the procedure was halted for a short period of time to allow the operative resuscitation to continue by Anesthesia and she began to receive blood products at this point.  Once the transfusion had been initiated, her blood pressure recovered safely without the aid of vasopressin agents and the exploration continued.  The omentum was then divided across the midpoint using a LigaSure device.  As the oozing from these enlarged, higher pressure vessels appeared to be the major source of her hemorrhage.  This thickened inflamed omentum was then passed off the field as specimen.  The line of division formed by the LigaSure device was then oversewn.  Exploration then continued.  The gallbladder was unable to be visualized.  There was significant amount of ascitic fluid around the hardened liver.  This fluid appeared to be clearer than the pericolic purulent drainage noted earlier.  The left upper quadrant appeared to be in a similar position with clear ascitic fluid.  The descending colon had a similar pericolic purulent drainage, but was found as extensive as on the right; however, in the pelvis itself, the sigmoid colon was adhered to the uterus.  The sigmoid colon was mobilized circumferentially and examined it for any evidence of perforation and separated from the uterus.  The uterus itself had appeared to be thinned over the exterior surface, but did not appear to be frankly injured.  The abdomen was then copiously irrigated with sterile saline.  The small bowel was then again run and the previously noted serosal tears were examined.  The patient at this point was quite oozy from many of the detached inflamed surfaces.  This hemorrhage was controlled using standard hemostatic techniques.  Examination of the abdomen did not denote any sign of a frank perforation.  However, there was the sequelae of it throughout the abdomen, but focused mostly in the pelvis and right lower quadrant. All areas of the abdomen appeared to be hemostatic and there were no other lesions noted.  An NG tube was placed under direct vision and the abdomen was then closed.


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## bill2doc (Sep 18, 2012)

49255 is seperate proc but not sure which to attch it too ????


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## FTessaBartels (Sep 21, 2012)

*44603,  44955*

I would use 44603 and 44955.  The omenectomy will be bundled and no modifier can be used, per CCI edits. 

I recommend this because the description seems to indicate that the several serosal tears which were found were NOT caused by the surgeon. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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