# Gun Shot Wound  Expl Lap, Splenectomy, distal panc., nephrectomy



## bill2doc (Feb 2, 2012)

Does anyone agree with 48140 w/ 50220-51 ?????

PREOPERATIVE DIAGNOSIS: Gunshot the left thoracoabdominal region. 

POSTOPERATIVE DIAGNOSES: 
1. Gunshot the left upper quadrant of the abdomen. 
2. Injury to the spleen and left kidney. 

PROCEDURES: 
1. Exploratory laparotomy. 
2. Splenectomy with distal pancreatectomy. 
3. Left nephrectomy. 
4. Evacuation of the bladder with primary repair. 

FLUIDS: Include 8 units of packed red blood cells, 4 units of FFP, 1 pack of platelets, and 3-1/2 liters of crystalloid. 

SPECIMENS INCLUDE: 
1. Bullet fragments. 
2. Spleen. 
3. Left kidney. 

INDICATIONS: Gunshot wound to the left thoracoabdominal region. Gunshot wound in the flank area showed evidence of extruding omentum. A chest x-ray was performed to rule out a pneumothorax and the patient was then brought to the Operating Room for an emergent exploratory laparotomy. 

DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room and placed in the supine position. The abdomen was then prepped and draped in standard fashion. A generous midline incision was then made and carried down through the subq fat and fascia. The fascia was incised after coordinating with anesthesia and the abdomen was then entered. Of note, there was a significant amount of blood immediately noted upon entry into the abdomen. The abdomen was then packed tightly in 4 quadrants. 

At this point, the patient became hypotensive. The patient was allowed to be resuscitated further by anesthesia with volume and blood products. Once the patient returned to normotension the packs were then evacuated in a systematic manner, beginning in the right upper quadrant, where no injury to the liver or stomach was noted, continuing down to the right lower quadrant where the bowel and right colon appeared to be intact. The pelvis was notable for a significantly distended bladder. Of note, preoperatively the patient has been complaining of continuing need to pee and had attempted to urinate. All that was returned was blood. A Foley was then placed preoperatively and blood clots were noted, but there did appear to be good flow of urine. However, at this point the bladder was becoming progressively distended within the pelvis. 

The packs were removed from the left lower quadrant and there is no evidence of ongoing bleeding or hemorrhage from the left colon or sigmoid. Attention was then focused on the left upper quadrant, where the packs were removed and immediately the patient was noted to have a shattered spleen, which had been partially mobilized by the wound. The wound appeared to go through the distal aspect of the pancreas. The splenic artery was palpated near the hilum and hemostasis was achieved by pressure while the kidney was then dissected from the surrounding tissues. The splenic artery and vein were then clamped as one and suture ligated. The hilum was then divided. The spleen and what appeared to be the tail end of the pancreas was then passed off the field as specimen. Deep to this wound expanding retroperitoneal hematoma was identified. 

Attention turned towards the bullet wound, which was quickly explored. The left abdominal wall noted a large tissue defect with some exposure of the bone of the 12th rib, but no evidence of diaphragmatic injury as could be immediately assessed. Attention then turned towards the hematoma, which had been followed and noted to be continued to expand. The left colon was then mobilized medially by identifying the white line of Toldt and dividing the peritoneal attachments along this plane. The hematoma appeared to be isolated to the left perinephric area and did not track caudally beyond the bifurcation of the aorta. The ureter was easily identified during the colonic mobilization and was noted to be dilated and darkened, concerning for blood. It was at this point that an intraoperative consult was called for Urology and 

The reflected colon allowed identification of the bifurcation of the aorta, which was then tracked proximally and minor periaortic branches were identified, plicated and divided. The left renal vein was then identified as it crossed the aorta. It was circumferentially dissected and a vessel loop was then placed around it for control. There is a small vessel initially superior to the renal vein, which initially was thought to be the renal artery; however, palpation of the posterior and deep aspect of the vein noted a pulsatile artery, which appeared to be more in line with the usual anatomic position. The previously mentioned vessel was circumferentially dissected and a vessel loop was placed. The now identified renal artery was also circumferentially dissected. It was doubly tied using 0 silk on either side of the area of concern and then was sharply divided. The left renal vein was then divided in a similar fashion. 

The retroperitoneal hematoma was then entered. The capsule was circumferentially dissected and was also entered. The hematoma was evacuated as much as was able. The identified vessel that was still marked with a vessel loop was at this point noted to be the atrial vein, which was similarly tied with 0 silk and divided. The entire mass was then able to be circumferentially dissected from the surrounding tissue. The ureter was traced, doubly clipped proximally and distally and then divided. The kidney was then also passed off the field as specimen. The abdomen was then copiously irrigated and hemostasis was maintained in the retroperitoneal space. 

At this point, the duodenum could easily be identified. The aorta was thoroughly examined up to the level of the diaphragm. There are no other vascular injury was identified. Attention was then turned towards the bladder, which had expanded considerably. Stay sutures were placed on either side of the bladder and the bladder was incised and then entered. There was some urine, but a significant amount of blood clot noted within the bladder. This was manually evacuated and the bladder was then copiously irrigated. The bladder was then repaired in 2 layers using 2-0 Vicryl. The Foley placement was noted to be accurate per intraoperative assessment. This Foley catheter will need to be a long-term indwelling Foley for at least a week given the bladder repair. 

Attention was then turned towards the retroperitoneal space, which was again examined for any ongoing bleeding. None was found. The bowel was then run formally from the ligament of Treitz to the cecum and there is no evidence to indicate injury to the small bowel. The large bowel was again reexamined. Of note, the retroperitoneal attachments had been infiltrated by some of the hematoma, which made examination of the colon difficult, but there is no evidence of injury noted. A #10 flat JP drain was then placed in the pancreatic bed due to assumed leakage, secondary to the distal pancreatectomy. This JP was brought out through a separate stab incision and then sutured to the skin using 3-0 nylon. Despite the significant amount of fluid the patient had received, there is not much remaining edema in the bowel and the patient was therefore able to be closed primarily using #1 looped PDS for the fascial sutures. Prior to closure the NG tube was verified to be in good position. The skin was then closed with staples. The wound packed overnight with Nugauze. Dressings were then applied.


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## jmcpolin (Feb 2, 2012)

I tried on this one but I can't seem to find a code for the bladder procedure.


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## bill2doc (Feb 2, 2012)

I couldn't either.  What do you think of the codes for the other procedures?  Those were as close as I came as well.... Thanks for trying!


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## jmcpolin (Feb 3, 2012)

48190
50220-52
53899 unlisted for bladder 

what do you think?


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## dmcbass (Jun 11, 2020)

Your codes for this case are 48190, 50220-51 not a 52 there is no reduced service here, for the bladder 51040-51


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