# What do you think???



## mhefner5 (Jul 24, 2012)

I am attaching an operative report from my surgeon that did a reversal of a Nissen thru laproscope. There is not a code for a take down or a revision. From the op report I am thinking the adhesiolysis would be a code choice, and the other would be an unlisted code. Please let me know all of your opinions, *they are all greatly appreciated.* 

PREOPERATIVE DIAGNOSES

1. Status post Nissen fundoplication with inability to belch or vomit without improvement in her cough symptoms.

2. Status post abdominal surgeries.
POSTOPERATIVE DIAGNOSES

1. Status post Nissen fundoplication with inability to belch or vomit without improvement in her cough symptoms.
2. Status post abdominal surgeries - status post ventral herniorrhaphy with mesh, with dense omental adhesions requiring
60 minutes of adhesiolysis to obtain visualization to take her Nissen fundoplication down. In the course of this dissection we discovered an incarcerated ventral incisional hernia at the site of one of her trocar sites.

PROCEDURE PERFORMED
Laparoscopic reversal of Nissen fundoplication after extensive (60 minutes) adhesiolysis, followed by repair of ventral hernia.

ANESTHESIA

DESCRIPTION OF OPERATION
The patient was brought to the operating room after informed consent was obtained. General endotracheal anesthesia was induced without incident. With the patient in the dorsal decubitus position the abdomen was prepped and draped in the usual sterile fashion.

With the patient in slightly head-down position the supraumbilical area was approached and attempted Veress needle introduction performed, but this was unsuccessful. For this reason, a left upper quadrant 5 mm port was placed under direct vision with the patient in steep reverse Trendelenburg position and the abdomen could then be assessed and was found to contain a tremendous amount of omental adhesions to a midline ventral hernia repair with mesh. Because of the location of these adhesions, two lower quadrant infraumbilical 5 mm ports were placed. Working through these ports I was able to free up the bilateral upper quadrants and place ports in both subcostal areas at the lateral clavicular lines and then alternately working through all four ports. Flow and meticulous dissection was performed to take down the patient's omental adhesions to her abdominal wall, assess her for any potential small bowel injury of which there was no evidence, and then progressively take down her adhesions in her left upper quadrant to demonstrate her fundoplication. Slowly, as the dissection was performed, I was able to place a liver retractor and this greatly facilitated the takedown of her post-Nissen adhesions and demonstrate her wrap which was then dissected free of surrounding structures and released in the routine fashion. After takedown of her wrap, the majority of the wrap was mobilized. I did not completely mobilize the retroesophageal portion of her wrap because of a tremendous amount of scar, the fact that her wrap had been secured to her diaphragmatic repair, and my concern over a vascular injury given the absolute elimination of all tissue planes. I was satisfied with the takedown from the perspective of enabling the patient to belch and vomit. I should note that in the course of her adhesiolysis a right upper quadrant incarcerated ventral hernia was encountered and this was taken down with meticulous technique. It was found to be actually fairly extensively defected into her musculature. Using an Endo Close device, after the completion of the takedown of the wrap and demonstrating excellent hemostasis as well as no evidence of any leak, ascertained by filling with methylene blue dye and dilute peroxide and saline. The patient's ventral hernia was closed with two interrupted #1 Prolene sutures using an Endo Close device after performing an appropriate counter incision for this site. I should also note that after the adhesiolysis two 10 mm left upper quadrant ports as well as a flexible 5 mm left subxiphoid port were placed prior to undertaking the takedown of the wrap. The two 10 mL ports were similarly closed with the Endo Close device and #1 Prolene suture. I should also note that prior to the port removals, a single 2-0 Tevdek suture was used to reinforce superficial serosal tear at the GE junction, even though there was no evidence of leak or even significant muscular injury. Similarly, prior to removal of the trocars and repair of the trocar sites, excellent hemostasis
was demonstrated at the trocar sites. 

After endoscopic closure of the patient's ventral hernia repair as well as the two 10 mm ports, abdomen was desufflated, the laparoscopic aspect of the procedure was terminated and the patient's wounds irrigated with dilute Betadine and saline. All the wounds were closed at the subcutaneous and subcuticular levels with 4-0 Monocryl suture and the skin with Steri-Strips. Sterile dressings were then applied and the procedure terminated.

There were no complications. Estimated blood loss was negligible. Fluids administered were 1500 mL crystalloid. The initial sponge, needle, and instrument count was correct. No drains were placed.


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