# Exp lap, Complex lysis of adhesions



## bill2doc (Jun 18, 2012)

Can I get help please.  I thinking 49005-22 w/ 49040-51??  Am I way off??? Thanks in advance !

1.  Exploratory laparotomy.
2.  Complex lysis of adhesions.
3.  Biopsy of perforated duodenal ulcer for a Graham patch repair of perforated duodenal ulcer.

DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room, placed in supine position.  A midline incision was then made through the previous laparotomy scars.  Immediately beneath the skin there  appeared to be a mesh that was mostly incorporated.  This mesh was incised in the midline and the abdomen was entered.  There is a significant amount of abdominal fluid that had both a purulent and bilious character.  Of note, directly under the mesh on either side, there is a significant amount of bowel that was adhesed to the wall and the overlying mesh.  Due to the presence of these adhesions, a full characterization of the location of the perforation could not be performed and extensive lysis of adhesions was initiated that lasted approximately 45 minutes.  The bowel was sharply dissected from the wall and allowed to return to the abdomen.  Once these adhesions had been lysed, the bowel was run.  It appeared to be thickened and mildly dilated in character but from the ligament of Treitz to the ileocecal valve, no gross injuries were noted.  There were small areas of further adhesions which were also lysed.  The colon was then traced from the cecum to the sigmoid and rectum.  There were no areas of perforation.  The patient was noted to have a significant amount of epiploica but there is no gross external evidence of perforated diverticula that could lead to the clinical picture.  

Attention then turned towards the upper abdomen.  Over the dome of the liver there was a significant amount of increased purulent fluid and frankly bilious drainage as well.  Palpation of the area identified a large ulcer whose size is approximately 1.5 cm in diameter.  

The abdomen was then copiously irrigated and this area was further examined.  It did not appear that there is much in the way of omental migration.  It is likely that due to the significant amount of omentum that had adhered to the mesh, the omentum was no longer in a position to migrate to inflammatory areas.  A biopsy of the edges of the ulcer was obtained with Tru-Cut needle as well as scissors.  These biopsies are passed off the field as a specimen.  The biopsy edges were then reapproximated using 3-0 Vicryl in large bites that were taken out to healthy tissue.  A tongue of thickened omentum was identified and isolated as it came off the stomach.  Three Lembert sutures were placed on either side of the ulcer and left in place.  The omentum was then brought across the ulcer and the previously placed sutures were tied down creating the Graham patch.  The abdomen was again copiously irrigated with warm sterile normal saline.  No other acute pathology was noted outside of the obvious inflammatory changes secondary to the ongoing intra-abdominal process.  The midline incision was then closed using looped PDS incorporating his fascia of the previously placed mesh.  Skin was closed with staples.  Dressings were then applied.  The patient was allowed to awaken from anesthesia and brought to the ICU in critical condition.


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## FTessaBartels (Jun 18, 2012)

*Bundled*

Lysis of adhesions (CPT 44005) will always be bundled into any more definitive procedure.  It is considered necessary for the approach.

However, if extensive lysis of adhesions is documented you may append a -22 modifier to the main procedure.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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