# hiatal hernia plus placement gastrostomy tube



## rkindlund (Jan 13, 2014)

Our general surgeon recently did a hiatal hernia repair along with placement of gastrostomy tube. Dictated this:

He is suggesting a 43653 but this is a separate procedure, so I don't think that would be right. Any suggestions as to how to capture the gastrostomy tube placement? Thank you.


Patient brought to the operating room, prepped and draped 

in the standard sterile fashion.  He was given 2.5 grams of IV Metrocef on 

induction of anesthesia.  I began by making a midline incision to just below the

xiphoid to just below the umbilicus, entered the peritoneal cavity without any 

difficulty.  A Bookwalter retractor was placed.  I then reduced the stomach and 

duodenum from inside the chest, down to an intra-abdominal location and 

proceeded by dissecting the phrenoesophageal membrane until I was able to 

identify both the right and left crura.  There was a hiatal hernia defect.  I 

did place a nasogastric tube from anesthesia into position of the stomach, and I

then grasped each side of the crura with the Babcock instrument and then using 

pledgets on an 0 Surgilon suture, I reapproximated the crura.  At first, I had 

placed 2 stitches, but this seemed a little too tight and so after removing the 

second stitch, I was able to still admit a fingertip between the esophagus and 

the hiatus, and this seemed to be a comfortable position anatomically.  Next, to

help keep the stomach intraabdominal, I placed a gastrostomy tube in the antrum 

of the stomach.  I first took a 3-0 silk suture, made a pursestring.  I then 

made a small gastrotomy with electrocautery and inserted a gastrotomy tube.  

This was a 16-French.  This had a 5 mL saline balloon which I deployed and then 

tacked the stomach up to the lateral left side of the abdominal wall and the 

stomach held nicely in position without much tension and the gastrostomy tube 

was secured into position externally on the skin.  I did then irrigate with some

warm saline.  There was good hemostasis.  The sponge and needle count were 

correct and I finally closed the wound with 0 looped PDS at the fascial level 

and the skin was closed with staples.  Patient tolerated the procedure well.


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## rkindlund (Jan 17, 2014)

*anything?*

Still hoping for responses here


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## cynthiabrown (Jan 17, 2014)

That is a laparoscopic code......43830 is the open code but it is not billable with hiatal hernia repair


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## rkindlund (Jan 20, 2014)

Thank you! I should have caught that it was a laparoscopic code.


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