# Conversion to laparatomy/lysis adhesions/BX's/Repair enterotomy/Fedding JJ



## Trendale (Jul 28, 2009)

Hello,
Please assist with the following op report:
I know I don't code the Diagnostic Lap. I believe I don't code the laparatomy as it is a component of the main PX, in which I beleve is the massive lysis adhesions. The code I am looking at for Feeding JJ is 49441, and I am not sure about the BX's. I believe the repair enterotomy is included ( incidental) as well. The port placement I have: 36561 and 77001-26.I also know to code V64.41 to show the conversion.


PREOPERATIVE DIAGNOSIS:  Gastric carcinoma.
POSTOPERATIVE DIAGNOSIS:  Pancreatic pseudocyst cancer with intubation
into the entire stomach from the esophagogastric (EG) junction down to
the antrum.
NAME OF OPERATION:
1 Diagnostic laparoscopy
2 Conversion to laparotomy.
3 Massive lysis of adhesions.
4 Pancreatic pseudocyst biopsy times 2.
5 Stomach biopsy.
6 Repair of enterotomy.
7 Feeding jejunostomy and port placement.  The port placement would be
dictated separately.
ANESTHESIA:  General anesthesia with intubation.
ESTIMATED BLOOD LOSS:  About approximately 250 cc.
ASSISTANT:  Herold Lessage
GROSS OPERATIVE FINDINGS:  There was a large amount of adhesions from
his previous bouts of pancreatitis and surgery.  Then, we took about
2.5 to 3 hours just lysis of adhesions, so that we can get to the area
of pathology.  The patient had a big tumor in the area of the fundus
very close to the EG junction.  In addition, he also had a very large
pseudocyst which was essentially the size of the stomach with cancer
in multiple sites causing erosion into the stomach.  The biopsy of the
stomach was positive.  In addition, biopsy coming from the pseudocyst
itself was positive for cancer.  Also, there was invasion of the
cancer into the stomach in the distal stomach, body, antrum, and the
first part of duodenum which was also positive for cancer as well.
DESCRIPTION OF OPERATION:  The patient was brought to the operating
room, positioned on the operating table in supine fashion.  After
induction of anesthesia with intubation, the abdomen was prepped and
draped in the usual sterile fashion.  Marcaine 0.5% plain was used to
infiltrate in the left upper quadrant subcostal midclavicular line.
Using the 0-degree scope with the 12 mm Xcel port, we went through the
different layers of the abdomen.  Abdomen was insufflated with CO2 to
15 mmHg.  Under direct laparoscopic vision, we placed a 5 mm port in
the right upper quadrant and one in the right lower quadrant.  We
began taking down some of the adhesions.  The adhesions were very
dense, making dissection very difficult.  The stomach was essentially
walled to the anterior abdominal wall, making dissection difficult.
We,  therefore, switched to the laparotomy.  Under laparoscopic
technique, we entered the abdomen through a standard mid abdominal
incision from the xiphoid to about 2 fingerbreadths past the
umbilicus.  A Bookwalter retractor was placed and we began continue
lysis of adhesions.  Again, the bulk of the case was used taking down
the adhesions.  About 2-1/2 was just lysing adhesions so that we can
get to the area of pathology.  Using our LigaSure, we began taking
down the short gastrics in the greater curvature moving towards the
area of the EG junction.  We went to the area of the spleen and again
began taking down the short gastrics until we were very close to the
EG junction.  We now began dissecting posterior to the stomach.  Blunt
digital dissection was used.  We entered the pseudocyst and some fluid
came from the pseudocyst.  We sent for biopsy of this crater like area
and it actually showed cancer.  In addition, an intervention
enterotomy was made on the anterior part of the stomach.  We reached
in and then took a biopsy which also came back positive for cancer as
well.  The enterotomy on the stomach was repaired using Endo-GIA 60.
We now continued dissecting the posterior aspect of the stomach and
continued up towards the EG junction.  Once we were up at the EG
junction, there was lot of scar tissue that we slowly were able to put
a finger around all the way to the EG junction and put a Penrose
drain.  We now dissected some of the esophagus, so that we can get to
good clean margins.  As we were coming down past the palpable mass in
the stomach, we began dissecting posterior to the stomach and closer
to the antrum and the duodenum so that we can mobilize the stomach at
the site and later bring it up  to perform our anastomosis.  However,
as we were dissecting close to the antrum and the second part of the
duodenum, we also noticed a very hard mass which was eroding into the
stomach.  We biopsied this.  Unfortunately, this one came back
positive for cancer as well.  So, the patient had cancer in 3 parts by
the EG junction, in the stomach itself,  and also in the distal
stomach and capsule of the pseudocyst.  It seems that the pseudocyst,
which was very elongated and calcified and went all the way from the
head of the pancreas to the area of the EG junction, contained all the
cancer, since all the biopsies came positive and it was indeed already
invading into the stomach at all parts.  I could not do a total
gastrectomy in this 74-year-old male.  He would not tolerate this
procedure well, so I can deemed to just, at this point, placed a
feeding jejunostomy tube and the port, so that he can ??<__________>
his chemotherapy.  Once we have biopsied the parts and determined that
this was extensive disease, we used an French T-tube.  We made a small
pursestring on the small intestine at about 20 cm from the ligament of
Treitz.  The small enterotomy was made on the middle of the
pursestring, and the T-tube placed into the stomach and then tied.  We
then sutured it to the anterior abdominal wall, after bringing the
T-tube through a different stab wound incision in the right upper
quadrant.  Once we placed the feeding jejunostomy in, we irrigated.
We removed all of our laparotomy packs.  There was some bleeding
coming from the area of the spleen, from  a small splenic laceration,
which we easily controlled with cautery and then placed a piece of
Surgicel.  We now placed a 19 French round Blake drain to drain the
area of the spleen and posterior to the stomach.  The 2-0 silk was
used to hold the drain in place.  We now performed closure.  Closure
was done with a #1 PDS in a running fashion and then the skin incision
was closed with staples.  Patient tolerated the procedure quite well.
He was then repositioned and reprepped and redraped so that we can do
our port placement.  The port placement will be dictated separately.




                          PORT PLACEMENT PX: DOB -1938

I have :36561 and 77001-26


PREOPERATIVE DIAGNOSIS:  Pancreatic pseudocyst cancer with spread to
the stomach.
POSTOPERATIVE DIAGNOSIS:  Pancreatic pseudocyst cancer with spread to
the stomach.
PROCEDURE PERFORMED:  Port placement.
ANESTHESIA:  General anesthesia with intubation.
ESTIMATED BLOOD LOSS:  Minimal blood loss, about 5 cc.
DESCRIPTION OF OPERATION:  The patient was positioned on the operating
table in supine fashion.  After induction of anesthesia, the left
subclavian region was prepped and draped in the usual sterile fashion.
Using the access needle, the left subclavian vein was cannulated and
a guidewire passed into the superior vena cava under direct
fluoroscopic vision.  We now made a small incision about 1
fingerbreadth below the percutaneous stick and created a subcutaneous
pocket for the port.  The catheter was tunneled to come out from the
pocket to the percutaneous stick site and it was measured and cut to
size.  It was then attached to the port.  The vein was dilated over
the guidewire, then the dilator and sheath were placed over the
guidewire again, guidewire and dilator were removed, leaving the
sheath in place.  Tip of the catheter was placed into the sheath and
the catheter fed into the superior vena cava.  We were able to flush,
but we were not able to withdraw any blood and then fluoroscopy showed
that the catheter had gone across into the right subclavian.  Under
direct fluoroscopic vision, we now pulled it out partly and then
pushed it back in, until it made a curve down into the superior vena
cava.  Then it was able to flush and work without any problems.  A 0
Prolene was then used to attach the port to the anterior chest wall
and then closure was performed.  First, the subcutaneous tissue was
closed with 3-0 Monocryl and the skin was closed with a running 4-0
Monocryl in subcuticular fashion.  This was then followed by Benzoin
and Steri-Strips.  Patient tolerated the procedure quite well.  He was
then taken to recovery in stable condition.


Thanks in advance!


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