jwschroeterjr@gmail.com
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How would you code this procedure I'm confused which modifiers to use, would you use 58,78 or 79?
PREOPERATIVE DIAGNOSIS:
Small bowel obstruction.
POSTOPERATIVE DIAGNOSIS:
Small bowel obstruction and uterine fibroids.
PROCEDURE PERFORMED:
Exploratory laparotomy, lysis of adhesions.
ANESTHESIA:
General anesthesia.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
DRAINS:
None.
GROSS FINDINGS:
Patient is a 38-year-old female who has a history of bowel obstructions from adhesions. She re-presented with high grade partial obstruction last week. She was hospitalized and got better with conservative therapy. She was discharged, but immediately returned with progressive pain. X-rays revealed hung up barium in the small bowel from last week. She was taken to the Operating Room where at laparotomy we identified adhesions from her prior operations. There was a focal obstruction of the small bowel, this was at the distal small bowel. Everything proximal was markedly dilated and edematous, distally was decompressed. All the adhesions were lysed. The patient tolerated the procedure well.
PROCEDURE IN DETAIL:
The patient was taken to the Operating Suite, placed in the supine position, given general endotracheal anesthesia, a Foley catheter was inserted and the abdomen was prepped and draped in the usual sterile fashion. She had a lower right paramedian scar and this was excised with the scalpel. We then worked our way down through the old scar and carefully gained entry into the abdomen in the epigastrium. We opened the entire length of the scar carefully and freed adhesions as we went. There were numerous band adhesions. There was an obstruction of the distal small bowel from an internal hernia from adhesions. These bands were lysed, all of the bowel was mobilized from the ligament of Treitz to the ileocecal junction. The prior anastomosis was noted, was patent and the obstruction was just distal to this. We assured that the bowel was healthy. We irrigated the abdomen, aspirated all the fluid and assured hemostasis. The patient had marked fibroids of the uterus. We placed the bowel in a comfortable position and closed
the abdominal wall en masse with running #2 Nylon suture. The subcutaneous tissues were irrigated, the skin was closed with staples. Sterile dressings were applied. All sponge, needle and instrument counts were correct. The patient tolerated the procedure well and was transferred to the Recovery Room in stable condition.
PREOPERATIVE DIAGNOSIS:
Small bowel obstruction.
POSTOPERATIVE DIAGNOSIS:
Small bowel obstruction and uterine fibroids.
PROCEDURE PERFORMED:
Exploratory laparotomy, lysis of adhesions.
ANESTHESIA:
General anesthesia.
ESTIMATED BLOOD LOSS:
Minimal.
COMPLICATIONS:
None.
DRAINS:
None.
GROSS FINDINGS:
Patient is a 38-year-old female who has a history of bowel obstructions from adhesions. She re-presented with high grade partial obstruction last week. She was hospitalized and got better with conservative therapy. She was discharged, but immediately returned with progressive pain. X-rays revealed hung up barium in the small bowel from last week. She was taken to the Operating Room where at laparotomy we identified adhesions from her prior operations. There was a focal obstruction of the small bowel, this was at the distal small bowel. Everything proximal was markedly dilated and edematous, distally was decompressed. All the adhesions were lysed. The patient tolerated the procedure well.
PROCEDURE IN DETAIL:
The patient was taken to the Operating Suite, placed in the supine position, given general endotracheal anesthesia, a Foley catheter was inserted and the abdomen was prepped and draped in the usual sterile fashion. She had a lower right paramedian scar and this was excised with the scalpel. We then worked our way down through the old scar and carefully gained entry into the abdomen in the epigastrium. We opened the entire length of the scar carefully and freed adhesions as we went. There were numerous band adhesions. There was an obstruction of the distal small bowel from an internal hernia from adhesions. These bands were lysed, all of the bowel was mobilized from the ligament of Treitz to the ileocecal junction. The prior anastomosis was noted, was patent and the obstruction was just distal to this. We assured that the bowel was healthy. We irrigated the abdomen, aspirated all the fluid and assured hemostasis. The patient had marked fibroids of the uterus. We placed the bowel in a comfortable position and closed
the abdominal wall en masse with running #2 Nylon suture. The subcutaneous tissues were irrigated, the skin was closed with staples. Sterile dressings were applied. All sponge, needle and instrument counts were correct. The patient tolerated the procedure well and was transferred to the Recovery Room in stable condition.