# Lap appy w/ ligation of inferior epigastric artery



## Leanne (Apr 14, 2014)

Can open 37617 be billed w/ lap 44970 for following procedure?  Thank you!

PROCEDURE: Laparoscopic appendectomy with ligation, left inferior epigastric artery for hemorrhage.

....A 2cm umiblical incision was created sharply, deepened to linea alba 5mm incision made, a 5mm trocar placed.  Pneumoperitoneum created with carbon dioxide to a peak intracorporeal pressure of 15mmHg and a 30-degree laparoscope inserted and abdomen explored.

Exploration confirmed modest omental adhesions to anterior abdominal wall from previous cesarean section.  A very large 3cm diameter appendix was seen in the pericecal fashion in the right pericolic gutter.

5mm right upper quadrant and 12mm left lower quadrant trocars were placed....all adhesions to pericolic gutter and the cecum were taken down sharply.  The mesoappendix was taken with LigaSure device.  The base of appendix was 2cm wide, but with at least 3 to 3.5cm in the central portion with a large appendicolith precluding grasping in the central region.  This was pink, red, injected acute appendicitis, likely mucocele.  Endo-GIA staple device with a vascular cartridge was placed on the cecum at the base of the appendix fired and the appendix amputated.  This was placed in an Endopouch and removed through the left lower quadrant trocar site by extending the incison 1cm and actually having to cut the rectus muscle a little bit to get it through as it was at least 3.5cm in diameter.

In doing so, arterial blood welled up from this incision.  It clearly injured the inferior epigastric artery.  The incision was extended another 2cm.  A Kelly clamp placed in each side of the rectus controlling the bleeding.  A figure-of-eight 2-0 Vicryl stitch was replaced x4 closing the fascial defect.  Laparoscopic exploration from within revealed 100ml blood clot over the sigmoid colon, irrigated and evacuated.  An additional figure-of-eight 0 Vicryl stitch was placed with a suture passer laparoscopically to close the peritoneum nicely.

A 5ml of 0.25% bupivicaine was injected throughout the trocar site.  Irrigation was again performed and all free fluid recovered.  Wound was closed with 3-0 Monocryl subcutaneous and subcuticular sutures, Mastisol, Steri-Strips and dry dressing.  A figure-of-eight 0 Vicryl closed the umbilical fascia as well.


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