# Laparoscopic repair of gastrostomy with washout of peritoneal cavity and gastropexy



## Beth Chabot (Jun 8, 2011)

How do you bill this???  Patient is post op 4 days for Laparoscopic  Hiatel Hernia repair and now has a dislodged G tube.  I'm lost!!!  He removed the G tube, washed out the peritoneal cavity and performed Gastropexy. Help.


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## mjewett (Jun 8, 2011)

It's hard to know without seeing the op note. Could you post a scrubbed copy of the op note?  (with no patient name)

Thanks


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## Beth Chabot (Jun 13, 2011)

*Gastropexy op note*

PREOPERATIVE DIAGNOSIS:  Peritonitis likely secondary to dislodgement of gastrostomy tube

POSTOPERATIVE DIAGNOSIS:  Peritonitis with fairly extensive peritoneal soilage from dislodged gastrostomy tube

DATE OF OPERATION:  

OPERATION PERFORMED:
   1. Left radial arterial line.
   2. Laparoscopic repair of gastrostomy with washout of peritoneal cavity and gastropexy.

Surgeon: 

First Assistant:  

Anesthesia:  General

INDICATIONS:  is a 73 year old gentleman who is postoperative day number 4 from a laparoscopic hiatal hernia repair.  The patient was doing well at home until this morning when he had an episode of retching and noted the acute onset of severe abdominal pain.  He was seen at the Chesapeake Regional Medical Center emergency department where a CT scan showed the G tube had been dislodged, and some free fluid in the pelvis with a small amount of free air as well.  He was transferred to Obici Hospital, and after a long discussion with the family, consented for return to the operating room.

PROCEDURE DESCRIPTION:
After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating room table.  A Time Out was performed and the patient and procedure identified.  He had been in atrial fibrillation, and was given some medication to control this, and developed some hypotension, and prior to starting our case, the decision was made to place an arterial line.  I prepped the left wrist and a 20 gauge arterial line was placed without difficulty.  This was secured and connected to continuous monitoring.  At this point a Foley catheter was placed.  The patient was placed in modified lithotomy position.  The abdomen was prepped and draped sterilely.  Using the 5 mm 0 degree laparoscope, and a 5 mm Optivue trocar, the previous lower right midabdomen laparoscopy incision was opened and the peritoneal cavity was entered under direct vision.  Pneumoperitoneum was established.  Upon placing a 5 mm 30 degree laparoscope, 
a moderate amount of inflammatory changes were seen in the abdomen, as well as some soiling of gastric material.  Once of the additional 5 mm left lower abdominal ports was opened, and a 5 mm trocar was inserted here.  The suction irrigator was used to irrigate out the abdomen, and about 6 liters of irrigation was used to completely irrigate the abdominal cavity.  A nasogastric tube was placed and this actually came out the gastrostomy tube and was visualized in the peritoneal cavity, which allowed us to easily identify the gastrotomy.  The G tube was seen up on the anterior abdominal wall dislodged from the stomach.  The previous left upper 5 mm port was reopened.  A 5 mm trocar was inserted, and a laparoscopic liver retractor was placed, and the liver was elevated in order to visualize the entire stomach.  At this point the left midabdominal incision was up-sized to a 12, and an additional 5 port was placed at the umbilicus.  One additional 
5 mm port was placed in the left lateral abdominal wall to facilitate retraction.  At this point the omentum was grasped and divided with a harmonic scalpel in order to get a clear view of the posterior greater curvature of the stomach where the G tube had pulled through.  Once we had cleared the omentum from this area and definitively identified the hole in the stomach, the NG tube was withdrawn back into the stomach, and then using a #0 Vicryl Endo stitch, a tacking stitch was placed at the apex of the gastrotomy in order to elevate it.  The inferior aspect of the gastrotomy was elevated.  The hole was about 1-1/2 cm consistent with what one would expect from the GT pulling through.  An Endo GIA stapler with a green load was brought up onto the field and placed just below this gastrostomy which was elevated into the stapler, and using two firings of the Endo 45, we were able to staple out the gastrotomy.  It was placed in an Endopouch, 
and brought out through the 12 mm port site and passed off the field as a specimen.  At this point the repair was inspected and noted to be intact.  Another Endo stitch with #2-0 Vicryl was brought up onto the field, and an omental buttress was used to patch and reenforce the repair that we had just completed.  At this point the abdomen was again irrigated.  On the CT scan from Chesapeake Regional Medical Center, the patient had a fluid collection in the mediastinum which I thought was most likely seroma fluid collecting in the old hiatal hernia sac, and I discussed with anesthesia whether or not to try and interrogate this, which would require a fairly significant manipulation of the stomach, likely replacing the Penrose drain around the GE junction, elevating it, and then trying to get back under the patch that we had placed.  The patient had been hemodynamically labile through the case, and I made a decision not to continue with the surgery 
at this point since we had identified and repaired the problem.  A #15 round Jackson-Pratt drain was brought in through the lateral right sided port site, after removing a liver retractor, and this was brought across the stomach to drain the abdomen widely in the upper abdomen.  Using an Endo stitch and #2-0 Surgidac, generous bites of the anterior fundus were taken in two locations, and then using a laparoscopic suture passer, the ends of the suture were brought up through the abdominal wall in the upper midline in order to perform gastropexy, as was intended by the G tube in order to try and pex the stomach in the abdominal cavity and prevent recurrence of his hiatal hernia.  The abdomen was inspected one more time for hemostasis which was complete.  All ports, with the exception of the camera port were withdrawn, the gastrostomy tube was pulled out, and under direct vision, the pneumoperitoneum was released to ensure that the stomach 
came up to the anterior abdominal wall without tension, and it did.  At this point the camera was removed.  The gastropexy sutures were secured, and then the 12 mm incision for the port site in the left midabdomen was closed using a figure-of-eight #0 Vicryl suture to reapproximate the fascia.  The skin incisions were irrigated and closed with skin staples.  Sterile dressings were applied, and the drain was secured with a #2-0 silk suture.  The nasogastric tube was left in place.  The endotracheal tube was left in place, as was the left radial arterial line and the 15 round Jackson-Pratt line, and Foley catheter.  The patient was transferred to the intensive care unit intubated and in critical condition.  Report was called to Dr.  , the intensive care unit attending, to discuss our plan of care for the patient. Sponge, needle and instrument counts were correct at the end of the case.

ESTIMATED BLOOD LOSS:  Estimated at 25

FLUIDS:  He received two liters of Crystalloid, 1000 mL of Hespan.

URINE OUTPUT:  Approximately 60 mL


THANKS FOR YOUR HELP IN CODING............[/COLOR]


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## mjewett (Jun 13, 2011)

43840-52
49905

I prefer not to bill unlisted code, so when there is an open code, I will bill it with modifier 52 and type a note on your claim. The note usually states claim is reduced b/c was performed laparoscopic not open.  In my experience, this allows the claim to process, much more accurately, and faster than billing an unlisted code.

Hope this helps.


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## Beth Chabot (Jun 16, 2011)

*gastropexy*

Thanks for the advice/suggestions.  I will give it a try!


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