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Please help me code for this OP report Thank you
OPERATION PERFORMED:
1. Diagnostic laparoscopy.
2. Laparoscopic omentectomy.
3. Laparoscopic gastric wedge resection.
4. Multiple intraabdominal biopsies.
5. Laparoscopic band and port removal.
6. Laparoscopic lysis of adhesions.
POSTOPERATIVE DIAGNOSES: 1. Abdominal pain. 2. Worsening left shoulder pain. 3. Dysphagia. 4. Nausea and vomiting. 5. Food regurgitation. 6. History of foreign body in the abdomen. 7. Defunctionalized stomach portion. 8. Multiple peritoneal adhesions and calcified masses on omentum, stomach, and left diaphragm.
FINDINGS: Foreign body device around stomach, multiple scarring in stomach, calcified masses on the left diaphragm, unsure of cause of chronic and worsening left shoulder pain. Defunctionalized portion of the stomach from distortion of stomach. Gastric outlet obstruction, likely from the band device.
INDICATION: This is a 41-year-old female with a history of worsening chronic abdominal pain mostly in the epigastric area, as well as worsening left shoulder pain, dysphagia, nausea, vomiting, and history of foreign body placed in the abdomen. The patient had an upper EGD done that noted suture and some foreign body that was coming on the inside of the stomach, therefore a thorough exploration of the abdomen was decided to ensure or to assess the causes of her abdominal and left shoulder pain, unrelated to the lap band device. The patient also had dysphagia, nausea, vomiting, food regurgitation, decrease in the quality of her life, and due to the concerns of possible perforation of suture or into the diaphragm due to the chronic and worsening pain, it was decided that an exploration should be done.
OPERATION: The patient was identified in the preoperative holding area as the correct patient. All questions were answered at that time, risks and benefits of the procedure were discussed, and the patient wished to proceed with the operation. The patient was taken back to the operating room theater, placed in supine position with her arms stretched out. The patient was subsequently prepped and draped in the normal sterile fashion. A time-out was taken to correctly identify the patient as well as the correct procedure. The patient also received 2 g of Ancef perioperatively, and had sequential compression devices placed to her bilateral lower extremities. A small nick was made in the skin, and Optiview technique was used to get into the abdominal cavity. Once inside the abdominal cavity, several other trocars were placed without difficulty. Prior to placing the trocars, the patient had local anesthetic injected over her previous port site that was palpated. A nick was made over this port site, and using electrocautery. The port subsequently removed from the subcutaneous tissue, cut, and the tubing was placed in the abdominal cavity to be taken out later. Once inside the abdominal cavity, it was noted the patient had multiple scarring and adhesions with in the intraabdominal cavity, not just from the stomach, but in the greater omental area also. At approximately at least 1 hour was taken taking down all these multiple adhesions in order to assess what is the reason for the chronic abdominal pain, as well as left shoulder pain. A thorough exploration of the abdomen was done and lap band around the stomach was noted, likely the cause of her dysphagia and this was subsequently removed without difficulty, taken out of the left lateral port and all the pieces were identified. At which point, the scarring around the stomach was subsequently taken down in order for the patient to be able to eat appropriately again. The patient was noted to have multiple calcified little masses on her stomach, as well as the omentum. Unsure the cause, and therefore a wedge resection of her stomach was also taken to include this, as well as a defunctionalized piece of the stomach that appeared to be also slightly dusky. This was removed with a Covidien black load. A wedge resection was completed without difficulty, and removed and passed off as specimen. At which point, it was noted that the patient had multiple small calcifications and scarring on her left diaphragm, unsure of the cause. This was not noted on the right. This was likely the cause
of her potential chronic left shoulder pain radiating from the diaphragm that I initially thought may be some type of erosion of a foreign body device, but it was not. The patient had multiple calcified masses on her left diaphragm, very small in size, punctate lesions and biopsy of several of these were obtained and passed off as specimen. The patient was also noted to have this scarring and calcified punctate mass in her omentum also, and this was also carved out and passed off as specimen. Once this was done, I was hoping this exploration would give a reason for her chronic pain in these multiple biopsies. Unsure of the cause, will await pathology. Intraoperative EGD was performed to ensure there was no leak at the new staple line of the gastric wedge around the fundus site anterior on the stomach, and to ensure there was no damage to the stomach while taking down the fold that was initially over the band site done with suture. The patient appeared to have a known hiatal hernia repair also loose, still somewhat intact, and the intraoperative EGD did not show an obvious large hiatal hernia defect at the time. At which point, after the exploration was done and the potential cause was identified, the abdomen was desufflated. More local was placed in the incisions. The area where the port was removed was reinforced with Vicryl in order to close the trocar hole site, as well as the dead space. Staples were placed over the skin incisions. All sponges and needle counts were correct. The patient tolerated the procedure well and was subsequently transferred to PACU for further recovery and the mother was updated.
SPECIMENS: 1. Biopsy of diaphragm x2.
2. Mass on omentectomy.
3. Gastric wedge.
4. Scar tissue around stomach.
OPERATION PERFORMED:
1. Diagnostic laparoscopy.
2. Laparoscopic omentectomy.
3. Laparoscopic gastric wedge resection.
4. Multiple intraabdominal biopsies.
5. Laparoscopic band and port removal.
6. Laparoscopic lysis of adhesions.
POSTOPERATIVE DIAGNOSES: 1. Abdominal pain. 2. Worsening left shoulder pain. 3. Dysphagia. 4. Nausea and vomiting. 5. Food regurgitation. 6. History of foreign body in the abdomen. 7. Defunctionalized stomach portion. 8. Multiple peritoneal adhesions and calcified masses on omentum, stomach, and left diaphragm.
FINDINGS: Foreign body device around stomach, multiple scarring in stomach, calcified masses on the left diaphragm, unsure of cause of chronic and worsening left shoulder pain. Defunctionalized portion of the stomach from distortion of stomach. Gastric outlet obstruction, likely from the band device.
INDICATION: This is a 41-year-old female with a history of worsening chronic abdominal pain mostly in the epigastric area, as well as worsening left shoulder pain, dysphagia, nausea, vomiting, and history of foreign body placed in the abdomen. The patient had an upper EGD done that noted suture and some foreign body that was coming on the inside of the stomach, therefore a thorough exploration of the abdomen was decided to ensure or to assess the causes of her abdominal and left shoulder pain, unrelated to the lap band device. The patient also had dysphagia, nausea, vomiting, food regurgitation, decrease in the quality of her life, and due to the concerns of possible perforation of suture or into the diaphragm due to the chronic and worsening pain, it was decided that an exploration should be done.
OPERATION: The patient was identified in the preoperative holding area as the correct patient. All questions were answered at that time, risks and benefits of the procedure were discussed, and the patient wished to proceed with the operation. The patient was taken back to the operating room theater, placed in supine position with her arms stretched out. The patient was subsequently prepped and draped in the normal sterile fashion. A time-out was taken to correctly identify the patient as well as the correct procedure. The patient also received 2 g of Ancef perioperatively, and had sequential compression devices placed to her bilateral lower extremities. A small nick was made in the skin, and Optiview technique was used to get into the abdominal cavity. Once inside the abdominal cavity, several other trocars were placed without difficulty. Prior to placing the trocars, the patient had local anesthetic injected over her previous port site that was palpated. A nick was made over this port site, and using electrocautery. The port subsequently removed from the subcutaneous tissue, cut, and the tubing was placed in the abdominal cavity to be taken out later. Once inside the abdominal cavity, it was noted the patient had multiple scarring and adhesions with in the intraabdominal cavity, not just from the stomach, but in the greater omental area also. At approximately at least 1 hour was taken taking down all these multiple adhesions in order to assess what is the reason for the chronic abdominal pain, as well as left shoulder pain. A thorough exploration of the abdomen was done and lap band around the stomach was noted, likely the cause of her dysphagia and this was subsequently removed without difficulty, taken out of the left lateral port and all the pieces were identified. At which point, the scarring around the stomach was subsequently taken down in order for the patient to be able to eat appropriately again. The patient was noted to have multiple calcified little masses on her stomach, as well as the omentum. Unsure the cause, and therefore a wedge resection of her stomach was also taken to include this, as well as a defunctionalized piece of the stomach that appeared to be also slightly dusky. This was removed with a Covidien black load. A wedge resection was completed without difficulty, and removed and passed off as specimen. At which point, it was noted that the patient had multiple small calcifications and scarring on her left diaphragm, unsure of the cause. This was not noted on the right. This was likely the cause
of her potential chronic left shoulder pain radiating from the diaphragm that I initially thought may be some type of erosion of a foreign body device, but it was not. The patient had multiple calcified masses on her left diaphragm, very small in size, punctate lesions and biopsy of several of these were obtained and passed off as specimen. The patient was also noted to have this scarring and calcified punctate mass in her omentum also, and this was also carved out and passed off as specimen. Once this was done, I was hoping this exploration would give a reason for her chronic pain in these multiple biopsies. Unsure of the cause, will await pathology. Intraoperative EGD was performed to ensure there was no leak at the new staple line of the gastric wedge around the fundus site anterior on the stomach, and to ensure there was no damage to the stomach while taking down the fold that was initially over the band site done with suture. The patient appeared to have a known hiatal hernia repair also loose, still somewhat intact, and the intraoperative EGD did not show an obvious large hiatal hernia defect at the time. At which point, after the exploration was done and the potential cause was identified, the abdomen was desufflated. More local was placed in the incisions. The area where the port was removed was reinforced with Vicryl in order to close the trocar hole site, as well as the dead space. Staples were placed over the skin incisions. All sponges and needle counts were correct. The patient tolerated the procedure well and was subsequently transferred to PACU for further recovery and the mother was updated.
SPECIMENS: 1. Biopsy of diaphragm x2.
2. Mass on omentectomy.
3. Gastric wedge.
4. Scar tissue around stomach.