# Subtotal Gastrectomy w Roux-en-Y gastrojejunostomy, Billroth II procedure, etc



## ksb0211 (Oct 13, 2011)

Just want to share this in hopes of other opinions.  Surgeon did a subtotal gastrectomy that included a sentinel node biopsy.  I'm not sure if I am able to bill that out separately.  Any thoughts on this are greatly appreciated.  I'm thinking 43633, but don't want to miss anything.

PRE/POST-OPERATIVE DIAGNOSIS
Carcinoma of the stomach.

OPERATION PERFORMED
Exploratory laparotomy, subtotal gastrectomy with Roux-en-Y gastrojejunostomy, Billroth II procedure with sentinel node biopsy.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR after induction of adequate general anesthesia. The patient was prepped with DuraPrep and draped sterilely.  The skin was incised from the xiphoid process in the midline towards the umbilicus.  The fascia was opened, peritoneal cavity was explored.  There was no evidence of gross metastatic disease.  A mass was appreciated along the greater curvature just proximal to the ligament of Treitz.  Injection of methylene blue was utilized along the greater and lesser curvature.  Once this was done, the stomach was divided proximally, approximately 6 centimeters proximal to the lesion.  This was done utilizing the TA-60 stapling device.  Then the distal stomach was oversewn with running 3-0 silk suture.  The Harmonic scalpel was utilized and the tissue along the greater curvature was taken down to the level of the colon.  Then the omentum in continuity with the lesion was taken extending towards the second portion of the duodenum.  The tissue along the lesser curvature was taken down similarly.  The larger vasculature was suture ligated with 2-0 silk suture.  Lymph nodes consistent with sentinel nodes were identified, especially along the first and going to the second portion of the duodenum.  The pylorus was passed and the dissection allowed the distal stomach to be completely free well past the lesion and proximally the junction of the first and second portion of the duodenum.  The TA-60 with blue staples was then applied.  The suture line was oversewn to the level of the duodenal stump with interrupted 3-0 silk suture.  Good hemostasis was achieved.  The specimen was passed off.  Although all the tissue in continuity with the lymph node was taken, the lymph node did detach from the specimen and was passed off as a separate specimen.  The remainder of the exam was basically negative.

Attention was then turned to the small bowel.  The small bowel was divided approximately 20 centimeters distal to the ligament of Treitz.  The distal aspect of the bowel was then brought through an opening in the transverse mesocolon.  An anastomosis was performed by placing the small bowel against the posterior aspect of the proximal stomach.  Stay sutures of 3-0 silk were then placed.  The GIA stapling device was fired.  The enterotomy and the suture line was then reinforced with interrupted 3-0 silk suture.  Additional sutures of 3-0 silk were then placed high along the greater curvature to prevent any acute obstruction of the small bowel.  With this completed, the bowel was tacked to the rent in the transverse mesocolon with interrupted 3-0 silk sutures.  The Roux-en-Y gastrojejunostomy was then completed by anastomosing the two limbs of small bowel with the GIA-75 and closing the enterotomy with standard 2 layer suture closure of 3-0 Vicryl and interrupted 3-0 silk.  The wounds were inspected for hemostasis. A 10 millimeter Jackson-Pratt drain was placed.  The estimated blood loss was perhaps 400 mL  The midline incision was closed with running double stranded #1 PDS and closed with clips.  The patient tolerated the procedure and was taken to the recovery room and then
the intensive care unit in stable condition.


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