# Laps diaphragm repair



## ksrkelly7 (Sep 6, 2017)

Hi there.  Looking for a CPT for Laparoscopic repair laceration of diaphragm .  This was not a hernia repair.  I see the open code, 39501.  Do I need to use the unlisted code, 39599, unlisted procedure, diaphragm?

Thanks for your help!

Kelly C, CPC


Indication for Surgery 
18-year-old-male Tier I victim S/P stab wounds to left lateral chest, right abdomen, and right back. There is suspicion for a diaphragmatic injury on the left side, thus he has been taken to the operating room. He received Ancef prior to the incision.

Preoperative Diagnosis 
Stab wound to left lower chest; R/O left diaphragmatic injury, vs other intra-abdominal injury vs left hemothorax

Postoperative Diagnosis 
Stab wound to left chest with left diaphragmatic injury and left hemothorax

Operation 
1. Diagnostic laparoscopy
 2. Laparoscopic left diaphragmatic injury repair
 3. Left tube thoracostomy (28 French)
 4. Irrigation and closure of left chest stab wound



Findings 
1. 2 x 1 cm left hemidiaphragmatic injury, with clear visualization into left thoracic cavity.
 2. Stab wound located at 9th ICS AAL.
 3. No intra-abdominal injury, though it appeared the omentum in the vicinity of the diaphragmatic injury was slightly blood stained.


Technique 
The patient was placed supine on the operating room table. All pressure points were padded. Sequential compression device were functional even before the patient was intubated. The patient's chest and abdomen were prepped and draped in the usual sterile fashion with Chlora Prep solution. Standard three minute dry time was observed for the ChloraPrep. A surgical time out was conducted. A foley catheter was inserted, and urine was sent for a Utox. An orogastric tube was placed by the anesthesiologist.

 An incision was made in a linear 5mm fashion in the umbilicus. A Veress needle was used to access the abdominal cavity without consequence, and the abdomen was insufflated to 15 mmHg with CO2 gas. This was followed by placement of a 5mm trocar, in an Optiview fashion. A diagnostic laparoscopy was conducted. after discovering the diaphragmatic injury, a decision was made to place other trocars. Another 5mm trocar was placed in the epigastrium, while an 11mm trocar was placed in the left upper quadrant, under direct visualization.

 The diaphragmatic defect was repaired with two separate 0-Prolene sutures in a simple interrupted fashion. Since there was no other pathology, the 11mm trocar was discontinued followed by closure of the defect with 0-Vicryl suture, utilizing the Endoclose device. The abdomen was deflated of all CO2 gas, and the remnant trocars were discontinued. The skin incisions were approximated with 4-0 Vicryl suture, thence placement of dermabond.

 A site was chosen in the left chest for placement of the chest tube. A 1-1/2 cm incision was made in the usual fashion at the 6th ICS, followed by puncture of the pleura, finger sweep, and insertion of the chest tube to the 12 cm mark. The chest tube was anchored with #1-Ethibond. The stab wound site was irrigated followed by approximation of the skin with staples. Sterile dressings were applied.

 The patient tolerated the procedure well. Instrument, needle, and sponge counts were correct x2, at the completion of the operation.


Disposition 
Successfully extubated and transferred to the recovery room in satisfactory condition


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