rrrobinson05
Contributor
Please help, anyone with experience with these surgeries your help and/or advice will be sincerely appreciated. (TIA). I'm leaning toward these codes: 43313, 43328-51, 43653-77, 43338-51.
Pre-operative Diagnosis: Esophageal atresia
Post-operative Diagnosis: Same
Procedure:
1. Esophageal atresia repair
2. Collis gastroplasty
3. Closure of gastrostomy tube site and recreation of new gastrostomy tube site.
4. Rigid bronchoscopy
Indications: Patient is a 6 m.o. female presenting with esophageal atresia. Weight: (!) 5.485 kg (12 lb 1.5 oz) . She underwent g-tube placement shortly after birth and has now grown and is able to undergo esophageal atresia repair.
Operative Details: Madeline was brought to the operating room where they underwent general anesthesia.
Rigid bronchoscope was passed into the upper airway and once we passed the cords to the anesthesia circuit. The trachea was inspected and there is no evidence of an upper pouch fistula.
The area of the abdomen was prepped and draped in sterile fashion. A vertical midline incision was made and carried down through the subcutaneous tissue muscle layers using electrocautery. Once we entered the abdomen we did encounter a fair amount of adhesions from her prior surgeries. The liver was mobilized away from the anterior abdominal wall and away from the stomach and GE junction in order to allow for us to proceed. I felt that the current G-tube location was likely to be a barrier to pulling a portion of the stomach up into the chest and thereby put tension on the anastomosis therefore the current G-tube site was closed. Electrocautery was used to separate this from the anterior abdominal wall and the residual opening in the stomach was closed with running Vicryl suture and interrupted silk suture.The gastrohepatic ligament was opened and taken down up to the level of the diaphragm. The GE junction was identified and circumferentially controlled with an umbilical tape. The short gastrics were taken down in order to mobilize the fundus of the stomach. An Endo GIA stapler was then positioned at the angle of Hiss parallel to the esophagus pointing distally. This was then fired to create the gastroplasty and thereby lengthen the available effective esophagus. At this point the abdomen was temporarily closed. The skin was closed with staples and an Ioban was placed over the abdomen.
The patient was then positioned laterally with her right side up and we proceeded with the chest portion of the procedure. Chest was prepped and draped in a sterile fashion. A muscle-sparing posterior lateral thoracotomy incision was made. The muscles were entered through the oscillatory triangle allowing access to the chest wall. We then entered through the fifth intercostal space and stayed retropleural. The retropleural space was fully mobilized with blunt dissection. The upper pouch was then identified with forward tension placed on an OE tube by the anesthesiologist. A stitch was placed through the esophagus and through the OE tube in order to allow for retraction. Blunt dissection electrocautery were then used to mobilize the upper pouch as much as possible taking care anteriorly to not create any injury to the trachea itself. We then identified the distal esophagus through blunt dissection in the lower retroperitoneum. In the course of this dissection we did enter the left pleural space and at some point we can see ballooning of air in the right pleural space as well. This was mobilized down to the level of the GE junction and we then connected the points of dissection from the thoracic and abdominal cavities in order to allow for pulling of the neoesophagus created by the Collis gastroplasty into the chest. With this extra length of esophagus we had good positioning with only a small amount of tension expected on the anastomosis. Both proximal and distal esophageal pouches were then opened sharply. An end-to-end anastomosis was then created using interrupted Vicryl sutures. Once the back wall was in place a feeding tube was passed from the nose by the anesthesiologist through the anastomosis and into the stomach. Subsequently the anterior wall of the anastomosis was put in place as well. A Blake drain was brought through a stab incision on the chest wall and placed in the retropleural space next to the anastomosis. We then proceeded with closure of the chest. Even though he had entry into both pleural spaces, I did not have any suspicion of lung injury creating persistent pneumothoraces felt it was not necessary to place pleural chest tubes at this time. The ribs were reapproximated with interrupted figure-of-eight costal sutures. Muscle layers were reapproximated with Vicryl suture. Subcutaneous tissue was closed with Vicryl and the skin was closed with Monocryl. The drain was sutured in place with a nylon.
We then returned our attention to the abdomen. She was repositioned supine and the temporary dressing was removed. The abdomen was reprepped and draped in sterile fashion. The staples were removed. Upon inspecting the stomach we saw our newly created angle of Hiss was positioned at the diaphragm. We then chose a place on the stomach to replace the gastrostomy tube. Two pursestring sutures were placed at the chosen site. Electrocautery was then used to enter the lumen of the stomach. A new gastrostomy tube was brought through the abdominal wall and positioned within the gastrotomy. The balloon was inflated. The pursestring sutures were then tied in place and then used to tack the stomach to the anterior abdominal wall as well. We then proceeded with closure of the abdomen. The fascia was closed with running Vicryl suture. Subcutaneous tissue was closed with Vicryl and the skin was closed with Monocryl.
The area was cleaned and dried and sterile dressings were applied. The patient was taken to the pediatric intensive care unit intubated and in fairly stable condition.
Pre-operative Diagnosis: Esophageal atresia
Post-operative Diagnosis: Same
Procedure:
1. Esophageal atresia repair
2. Collis gastroplasty
3. Closure of gastrostomy tube site and recreation of new gastrostomy tube site.
4. Rigid bronchoscopy
Indications: Patient is a 6 m.o. female presenting with esophageal atresia. Weight: (!) 5.485 kg (12 lb 1.5 oz) . She underwent g-tube placement shortly after birth and has now grown and is able to undergo esophageal atresia repair.
Operative Details: Madeline was brought to the operating room where they underwent general anesthesia.
Rigid bronchoscope was passed into the upper airway and once we passed the cords to the anesthesia circuit. The trachea was inspected and there is no evidence of an upper pouch fistula.
The area of the abdomen was prepped and draped in sterile fashion. A vertical midline incision was made and carried down through the subcutaneous tissue muscle layers using electrocautery. Once we entered the abdomen we did encounter a fair amount of adhesions from her prior surgeries. The liver was mobilized away from the anterior abdominal wall and away from the stomach and GE junction in order to allow for us to proceed. I felt that the current G-tube location was likely to be a barrier to pulling a portion of the stomach up into the chest and thereby put tension on the anastomosis therefore the current G-tube site was closed. Electrocautery was used to separate this from the anterior abdominal wall and the residual opening in the stomach was closed with running Vicryl suture and interrupted silk suture.The gastrohepatic ligament was opened and taken down up to the level of the diaphragm. The GE junction was identified and circumferentially controlled with an umbilical tape. The short gastrics were taken down in order to mobilize the fundus of the stomach. An Endo GIA stapler was then positioned at the angle of Hiss parallel to the esophagus pointing distally. This was then fired to create the gastroplasty and thereby lengthen the available effective esophagus. At this point the abdomen was temporarily closed. The skin was closed with staples and an Ioban was placed over the abdomen.
The patient was then positioned laterally with her right side up and we proceeded with the chest portion of the procedure. Chest was prepped and draped in a sterile fashion. A muscle-sparing posterior lateral thoracotomy incision was made. The muscles were entered through the oscillatory triangle allowing access to the chest wall. We then entered through the fifth intercostal space and stayed retropleural. The retropleural space was fully mobilized with blunt dissection. The upper pouch was then identified with forward tension placed on an OE tube by the anesthesiologist. A stitch was placed through the esophagus and through the OE tube in order to allow for retraction. Blunt dissection electrocautery were then used to mobilize the upper pouch as much as possible taking care anteriorly to not create any injury to the trachea itself. We then identified the distal esophagus through blunt dissection in the lower retroperitoneum. In the course of this dissection we did enter the left pleural space and at some point we can see ballooning of air in the right pleural space as well. This was mobilized down to the level of the GE junction and we then connected the points of dissection from the thoracic and abdominal cavities in order to allow for pulling of the neoesophagus created by the Collis gastroplasty into the chest. With this extra length of esophagus we had good positioning with only a small amount of tension expected on the anastomosis. Both proximal and distal esophageal pouches were then opened sharply. An end-to-end anastomosis was then created using interrupted Vicryl sutures. Once the back wall was in place a feeding tube was passed from the nose by the anesthesiologist through the anastomosis and into the stomach. Subsequently the anterior wall of the anastomosis was put in place as well. A Blake drain was brought through a stab incision on the chest wall and placed in the retropleural space next to the anastomosis. We then proceeded with closure of the chest. Even though he had entry into both pleural spaces, I did not have any suspicion of lung injury creating persistent pneumothoraces felt it was not necessary to place pleural chest tubes at this time. The ribs were reapproximated with interrupted figure-of-eight costal sutures. Muscle layers were reapproximated with Vicryl suture. Subcutaneous tissue was closed with Vicryl and the skin was closed with Monocryl. The drain was sutured in place with a nylon.
We then returned our attention to the abdomen. She was repositioned supine and the temporary dressing was removed. The abdomen was reprepped and draped in sterile fashion. The staples were removed. Upon inspecting the stomach we saw our newly created angle of Hiss was positioned at the diaphragm. We then chose a place on the stomach to replace the gastrostomy tube. Two pursestring sutures were placed at the chosen site. Electrocautery was then used to enter the lumen of the stomach. A new gastrostomy tube was brought through the abdominal wall and positioned within the gastrotomy. The balloon was inflated. The pursestring sutures were then tied in place and then used to tack the stomach to the anterior abdominal wall as well. We then proceeded with closure of the abdomen. The fascia was closed with running Vicryl suture. Subcutaneous tissue was closed with Vicryl and the skin was closed with Monocryl.
The area was cleaned and dried and sterile dressings were applied. The patient was taken to the pediatric intensive care unit intubated and in fairly stable condition.