# Nissen & Partial stomach removal-PLEASE HELP



## Williealawishes (Aug 6, 2010)

Hello.  I am having a difficult time making a decision on this op report.  
I assume 43324 instead of 39502 (even though this states removing the stomach from the hernia)....having a problem finding a code to cover the partial stomach removal.
Any takers on this???  Please any help would be wonderful!!!!!
Thanks in advance....Tracy



PREOPERATIVE DIAGNOSIS: Perforated viscus with free air in the abdomen.

POSTOPERATIVE DIAGNOSES:
1. Large hiatal hernia with most of the stomach up in the chest.
2. Perforation due to ischemia from the posterior wall of the stomach.
3. Peritonitis.

PROCEDURE:
1. Exploratory laparotomy, splenic flexure takedown, reduction and repair
of a large hiatal hernia with Nissen fundoplication and crural repair.
2. Resection of ischemic perforated back wall of the stomach.
3. G-tube placement.
4. CVP line placement by Dr. 
5. Arterial line placement by Dr. 

The patient tolerated the procedure well.

SPECIMENS REMOVED:
1. Section of the back wall of the stomach.
2. Hiatal hernia sac.

ESTIMATED BLOOD LOSS: 100 mL

URINE OUTPUT DURING THE PROCEDURE: 200 mL

INDICATIONS FOR PROCEDURE: This patient presented to the emergency room
with a severe episode of abdominal pain. She states that she developed
significant episode of heartburn last evening and then this morning when
she got up and started moving around, she had significant increase in
abdominal pain. CT scan of the abdomen and pelvis were done by the
emergency room and this showed evidence for a loop of bowel consistent with
possible obstruction, also a significant amount of diverticulosis without
obvious diverticulitis, significant amount of ascites, some multiple cysts
in the liver along with a large hiatal hernia with most of the stomach up
in the chest.

Because there was some free air found on the CT scan and signs of ascites,
it was felt the patient was most likely had a perforation of the hollow
viscus that led to the free air and therefore the risks, benefits, possible
complications of exploratory laparotomy with possible sigmoid resection,
possible reduction of the stomach and need for crural repair and hiatal
hernia repair, and/or  repair of duodenal ulcer have been described to the
patient and the family and they seem to understand and wished to proceed.

DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on
the operating room table and after induction of adequate general
endotracheal anesthesia Dr.  placed a left-sided arterial line and a
right-sided IJ central venous catheter. We then placed a Foley catheter.
SCD hose were in place at the time of induction. Because of this, we
prepped and draped the abdomen with chlorhexidine and following this, we
carefully made a midline incision starting just above the umbilicus coming
a little bit to the right side.  I had palpated and I could feel a small
umbilical hernia at the time of the examination prior to her prep.
Therefore, we came very close to the umbilicus on this right side and then
down on the right side of the scar in the infra-abdominal area. Following
this, we carefully entered the abdomen just above the umbilicus where there
had been  no previous scar. There was immediately noted to be some dark
grayish fluid that did not have a fecal smell. We then carefully opened the
abdomen the rest of the way and began exploration. First I ran the small
bowel to the ligament of Treitz and then backwards to the ileocecal valve
and there was no bowel obstruction. There were not very many adhesions and
the small bowel was completely free of adhesions. There was significant
grayish material, this was suctioned and about 20 mL was sent in a Lukey
trap for culture and sensitivity and Gram stain. Following this, we checked
the sigmoid colon.  We were curious about one small area near the
rectosigmoid junction that appeared to be a possible diverticula, but we
could not find any specific air leaking or any specific inflammation in the
area. Therefore, we made a wider search. We carefully searched up the right
colon. There was noted to be a little bit of dark changes behind the
mesentery of the right colon, but no specific palpable masses or areas of
air bubbling or any other changes. We followed the entire transverse colon
from hepatic flexure all the way to the splenic flexure and this was fairly
pink and fairly unremarkable. I carefully inspected the splenic flexure and
the spleen. There was a little bit of adhesion up in that area, but
otherwise there was none that could explain the site of leakage of the
fluid. Because of this, then I decided to go ahead and pull the stomach out
of the chest. We could see that the pylorus was out of the chest and then
the rest of the stomach was up in the hiatal hernia. This was carefully
then grasped and reduced. Initially we could not feel the NG tube in the
distal stomach.  Then as we got more than half the stomach into the
abdomen, Dr. Freed could move the NG tube and was moved such that the tip
was down in the pylorus. Entire stomach was reduced back into the abdomen
without too much more difficulty and there was found to be a large hiatal
hernia sac that was shiny and lined with peritoneum. Following this, I
looked at the anterior surface of the stomach. It did not appear ischemic.
There was no obvious hole in this, there was no obvious hole in the
duodenum and we could not detect any specific site of leakage. Although we
suspected that this could be a problem, we could not find anything of
significance. I then carefully went back to the sigmoid, inspected this,
began freeing up the left colon along the left lateral border and then I
decided that sense it appeared that we could not find anything that was
definitely perforated, it appeared the sigmoid was inflamed enough that it
could be that as the source so I was going to plan to do a sigmoid
colectomy, but I decided I would like to go ahead and take down the splenic
flexure because there was some dark changes on the lateral side of the
splenic flexure and that would allow us more easily next  time to do a
colostomy takedown. I was thinking since it appeared that the most likely
spot of perforation was the rectosigmoid, to staple off the rectum and then
come up; however, as we began dissecting the splenic flexure into the
splenic flexure takedown we entered the lesser sac and noticed a new area
of purulence and then the omentum that was going up into the lesser sac was
identified to be stuck to the back wall of the stomach and as we worked on
the back wall of the stomach in the lesser sac, we pulled the stomach down
and rotated it and found a grayish area of stomach with a definite hole
present in it and leaking fluid. Because of this, we carefully put a
Babcock on this and there was another small hole just distal to it on the
greater curvature. It appears that the stomach must have torsed and became
ischemic. Therefore, we had found our hole, I decided not to do anything
more with the sigmoid, make sure that there was good hemostasis and then we
carefully inspected the hiatal hernia. We resected some of the hiatal
hernia sac and found the left and right crus. The esophagus was carefully
dissected to get rid of the hiatal hernia material and shiny lining. I was
able to find the left and right crus that we could use later for closure of
the crus behind the esophagus. Following this, as we dissected on the front
of the esophagus it looked like there was a very small hole at the
gastroesophageal junction but the NG tube was nicely in place.  We got it
completely around the esophagus behind it and it appeared to be well
vascularized. Therefore, I decided to go ahead and close this area with 3
small silk sutures and then we tied a piece of fat from the hiatal hernia
sac over this site to buttress it. We also then later placed the Nissen
fundoplication directly over the site. Following this, with the esophagus
loop with a half-inch Penrose drain, we carefully dissected up the later
al
side of the stomach, taking the vessels of the greater curvature along this
entire lateral side. This allowed us to put the TA 90 stapler across the
stomach at this site, removing the entire area of grayish stomach and then
this suture line was inverted with a running 2-0 silk suture. Following
this, we repaired the crura, passing 0 silk sutures through the strong left
crura, the slightly weaker right crura, then back and then through again,
and we did 3 sutures with this and this seemed to approximate the crura
nicely. The NG tube could be easily palpated in the hiatus and did not seem
to narrow the hiatus too much. Following this, I decided to go ahead and do
a Nissen fundoplication in order to try to keep the stomach down in the
abdomen, a section of the stomach in the high fundus was selected and
grasped with a Babcock and retracted over from the left side to the right
side and then sutures were taken on this anterior surface of the stomach
through bite of the serosa of the esophagus and then to the stomach on the
other side, 4 sutures were done with a length of about 2 to 2.5 cm and
tied, it seemed to invert nicely and did not seem to narrow the esophagus.
The stomach appeared healthy. The NG tube could be easily palpated along
the entire course from the curl closure all the way down into the stomach.
We still had enough room to do a gastrostomy tube; 3 cm off the midline in
the left upper quadrant we made an opening and then brought through a MIC
French 22-French gastrostomy tube and placed that through the abdominal
wall. Then placed 2 pursestring sutures of 2-0 silk on the anterior surface
of the stomach and made a small opening in this with Bovie and then with a
hemostat, spread it, and then put the G-tube into the stomach. The balloon
was blown up with 10 mL and the 2 pursestring sutures were tied and then
the lateral one was sutured just at the lateral side of the underside of
the peritoneum at the site of the G-tube.  The G-tube was pulled up to
about 3.5 cm at the mark on the G-tube and it was well off the midline. It
seemed to come out without tension. The other one was tied on the medial
side and these strings were cut and then we carefully inspected for
hemostasis. We irrigated the abdomen with a liter of saline and irrigated
away all of the purulent material that was up by the splenic spleen and
beneath the diaphragm on the left. There was a little bit of bleeding from
a spot on the right lobe of the liver that was carefully packed and then at
the end of the procedure the packing was removed. We carefully inspected
the entire area, there was no further bleeding noted.  After gastrostomy
was done, we carefully irrigated the abdomen and then began closure.

Closure was obtained with interrupted in figure-of-eight #0 to #1 Vicryl,
along with running loop Biosyn, along the entire course of the site right
at the umbilicus where the umbilical hernia an extra figure-of-eight suture
of 0 Vicryl was used to close the fascia just beneath the umbilicus and it
seemed to close up nicely. Following this, the wound was irrigated and then
staples were used to close the skin, Telfa 4 x 4's, Microfoam tape were
applied. The patient was taken to the recovery room in good condition. The
G-tube was connected to gravity drainage and the NG tube to low
intermittent suction. Foley catheter was left in place as well of the
arterial line and CVP line


----------

