daniel
True Blue
My main question is how would one just code the first two procedures.
Closure of duodenostomy with duodenal ileostomy anastomosis.
Closure of jejunostomy with jejunal gastric anastomosis.
thanks!
POSTOPERATIVE DIAGNOSIS:
Status post bowel resection for small bowel infarction.
Bowel discontinuity with tube duodenostomy and tube jejunostomy.
Omental mass.
Global dense peritoneal adhesions.
OPERATION PERFORMED:
Closure of duodenostomy with duodenal ileostomy anastomosis.
Closure of jejunostomy with jejunal gastric anastomosis.
Excision of omental mass.
Lysis of adhesions for 90 minutes.
FINDINGS: The patient had dense intra-abdominal adhesions, particularly in the para midline and left upper quadrant areas. She had a viable 5 cm length of terminal ileum present with normal adjacent appendix. There was a duodenal tube present in the fourth portion of the duodenum where it had been stapled and transected. The tube had a granulating tract leading to the left upper quadrant skin. There also was a jejunal tube present in the distal end of the jejunal conduit from the gastric pouch. The tube lead from the end of the jejunum to the left upper quadrant, with a granulating tract to the skin. In finding the proximal duodenum it was noted that a part of the gastric antrum was still present and attached to the pylorus and duodenum. All of the GI tract was viable and there was no area of ischemia present. A 4 cm mass was found in the right upper quadrant omentum and this was excised and sent to pathology.
RAPID FROZEN SECTION: None.
OPERATIVE PROCEDURE: The patient was placed into the supine position on the operating table. She was placed under general endotracheal anesthesia. Her abdomen was clipped of hair, the duodenostomy and jejunostomy tubes were cut off at skin level, and left with their sutures intact. The abdomen was then prepped and draped in the usual manner with a C-section drape over the top. A time-out was then held.
The wide midline incision was excised elliptically down to the fascia. The fascia was then opened with caution to avoid injuring the bowel. Once the fascia and peritoneum were opened adhesions were carefully dissected bilaterally until I was able to break free into the right lateral abdomen over the ascending colon. On the left-hand side adhesions continued all the way past the duodenostomy and jejunostomy sites until the descending colon could be identified.
A 5 cm mass was found in the omentum which appeared to be inflammatory. This was excised using clamps and ties of 2-0 Vicryl suture. This was sent to pathology for examination. The terminal ileum was identified. The appendix was adherent to it and these adhesions were lysed. The appendix was otherwise normal and was left in place. The right colon was then mobilized from the sidewall enough for the ileum to be mobilized into the midline.
The lysis of adhesions continued into the left upper quadrant area where the jejunostomy and duodenostomy tubes were located and these portions of the bowel were dissected free from adhesions with some difficulty in the left upper quadrant. This process took approximately a total of 90 minutes. When the duodenal area was freed the duodenum was mobilized and was able to be turned inferiorly to where it would easily anastomose to the terminal ileum. A stapled anastomosis was then performed between the fourth portion of the duodenum and the terminal ileum using a GIA stapler and a TA stapler in the usual fashion. Mesenteric defect was closed using a running 3-0 Vicryl suture. The anastomosis was noted to be wide open without any bleeding.
The jejunostomy site was also freed up. The jejunum was freed into the midline. It was noted that the tube jejunostomy did not come out of the end of the jejunum but approximately 8 inches from its terminus. This area was repaired in 2 layers using running and interrupted 3-0 Vicryl sutures. The end of the jejunum was then freed enough to mobilize over to the duodenum. When exploring the first portion of the duodenum it was noted that there was a remnant of gastric antrum approximately 10 cm long. We debated whether to remove this antrum or leave it in place and since it provided a way to do an anastomosis with less tension, the anastomosis was done between the distal end of the jejunal limb into the lesser curvature portion of the antral stump. This was also done using TA and GIA staplers and the mesenteric defect closed using running 3-0 Vicryl sutures. Hemostasis was obtained. The abdomen was irrigated with 2 L of saline. The anastomoses were checked for patency and bleeding and were found to be good. The remaining omentum was placed in the midline. Two sheets of Seprafilm were used, 1 above and 1 below the omentum. The abdominal wall fascia was then closed using running looped #1 PDS sutures. The duodenostomy and jejunostomy drain sites were curetted to remove all granulation tissue and then packed with half-inch ribbon gauze. The patient was a little oozy during the operation and 2 units of FFP were ordered but were not given until the patient was transported up to the surgical ICU. Due to the anesthesiologist's concern for anemia and postoperative pain she was left intubated and taken to the intensive care unit, where she was to remain until after she could be extubated.
Closure of duodenostomy with duodenal ileostomy anastomosis.
Closure of jejunostomy with jejunal gastric anastomosis.
thanks!
POSTOPERATIVE DIAGNOSIS:
Status post bowel resection for small bowel infarction.
Bowel discontinuity with tube duodenostomy and tube jejunostomy.
Omental mass.
Global dense peritoneal adhesions.
OPERATION PERFORMED:
Closure of duodenostomy with duodenal ileostomy anastomosis.
Closure of jejunostomy with jejunal gastric anastomosis.
Excision of omental mass.
Lysis of adhesions for 90 minutes.
FINDINGS: The patient had dense intra-abdominal adhesions, particularly in the para midline and left upper quadrant areas. She had a viable 5 cm length of terminal ileum present with normal adjacent appendix. There was a duodenal tube present in the fourth portion of the duodenum where it had been stapled and transected. The tube had a granulating tract leading to the left upper quadrant skin. There also was a jejunal tube present in the distal end of the jejunal conduit from the gastric pouch. The tube lead from the end of the jejunum to the left upper quadrant, with a granulating tract to the skin. In finding the proximal duodenum it was noted that a part of the gastric antrum was still present and attached to the pylorus and duodenum. All of the GI tract was viable and there was no area of ischemia present. A 4 cm mass was found in the right upper quadrant omentum and this was excised and sent to pathology.
RAPID FROZEN SECTION: None.
OPERATIVE PROCEDURE: The patient was placed into the supine position on the operating table. She was placed under general endotracheal anesthesia. Her abdomen was clipped of hair, the duodenostomy and jejunostomy tubes were cut off at skin level, and left with their sutures intact. The abdomen was then prepped and draped in the usual manner with a C-section drape over the top. A time-out was then held.
The wide midline incision was excised elliptically down to the fascia. The fascia was then opened with caution to avoid injuring the bowel. Once the fascia and peritoneum were opened adhesions were carefully dissected bilaterally until I was able to break free into the right lateral abdomen over the ascending colon. On the left-hand side adhesions continued all the way past the duodenostomy and jejunostomy sites until the descending colon could be identified.
A 5 cm mass was found in the omentum which appeared to be inflammatory. This was excised using clamps and ties of 2-0 Vicryl suture. This was sent to pathology for examination. The terminal ileum was identified. The appendix was adherent to it and these adhesions were lysed. The appendix was otherwise normal and was left in place. The right colon was then mobilized from the sidewall enough for the ileum to be mobilized into the midline.
The lysis of adhesions continued into the left upper quadrant area where the jejunostomy and duodenostomy tubes were located and these portions of the bowel were dissected free from adhesions with some difficulty in the left upper quadrant. This process took approximately a total of 90 minutes. When the duodenal area was freed the duodenum was mobilized and was able to be turned inferiorly to where it would easily anastomose to the terminal ileum. A stapled anastomosis was then performed between the fourth portion of the duodenum and the terminal ileum using a GIA stapler and a TA stapler in the usual fashion. Mesenteric defect was closed using a running 3-0 Vicryl suture. The anastomosis was noted to be wide open without any bleeding.
The jejunostomy site was also freed up. The jejunum was freed into the midline. It was noted that the tube jejunostomy did not come out of the end of the jejunum but approximately 8 inches from its terminus. This area was repaired in 2 layers using running and interrupted 3-0 Vicryl sutures. The end of the jejunum was then freed enough to mobilize over to the duodenum. When exploring the first portion of the duodenum it was noted that there was a remnant of gastric antrum approximately 10 cm long. We debated whether to remove this antrum or leave it in place and since it provided a way to do an anastomosis with less tension, the anastomosis was done between the distal end of the jejunal limb into the lesser curvature portion of the antral stump. This was also done using TA and GIA staplers and the mesenteric defect closed using running 3-0 Vicryl sutures. Hemostasis was obtained. The abdomen was irrigated with 2 L of saline. The anastomoses were checked for patency and bleeding and were found to be good. The remaining omentum was placed in the midline. Two sheets of Seprafilm were used, 1 above and 1 below the omentum. The abdominal wall fascia was then closed using running looped #1 PDS sutures. The duodenostomy and jejunostomy drain sites were curetted to remove all granulation tissue and then packed with half-inch ribbon gauze. The patient was a little oozy during the operation and 2 units of FFP were ordered but were not given until the patient was transported up to the surgical ICU. Due to the anesthesiologist's concern for anemia and postoperative pain she was left intubated and taken to the intensive care unit, where she was to remain until after she could be extubated.