Hi y'all- I would appreciate any suggestions you have for coding this op report- since our CV surgeon used veins for the grafts, we are stumped. Thanks in advance for your help!
PREOPERATIVE DIAGNOSIS
Chronic mesenteric arterial insufficiency.
POSTOPERATIVE DIAGNOSIS
Chronic mesenteric arterial insufficiency.
OPERATIVE PROCEDURE
Celiac and superior mesenteric artery bypass for chronic mesenteric arterial insufficiency.
SURGEON
Dr. A. , MD
FIRST ASSISTANT
Dr. B., MD
SECOND ASSISTANT
Mr. C
ANESTHESIA
Dr. D.
SKIN PREP
Alcohol and DuraPrep.
FINDINGS
This is a XX female admitted to the hospital on XXXXX, with bleeding gastric ulcers. Completion of her workup revealed severe ongoing chronic mesenteric arterial insufficiency. The patient has food fear, intestinal angina, and weight loss for the past 11 months. The risks versus benefits of proceeding with bypass of the celiac and superior mesenteric arteries were discussed with the patient and her family. They wished to proceed.
DESCRIPTION OF PROCEDURE
Patient underwent satisfactory general endotracheal anesthesia. The skin was scrubbed, prepped and draped in sterile fashion. A time-out was held. Two greater saphenous veins were harvested from the groin to above the knee on both sides. The veins were prepared. Layers were closed over 2 Blake drains. Lower body bear hugger was applied in conjunction with the already positioned upper body bear hugger.
The laparotomy incision was made in the midline. Bookwalter was inserted. The triangular ligament of the liver was divided and a left lobe of the liver was gently retracted backwards to be able to expose the aorta. This was done through opening the crus of the diaphragm. The celiac artery was relatively long and has minimal pulsation flow and has a long segment before it bifurcates into the common hepatic and splenic. After mobilizing this vessel proximally and distally, attention was then turned to the superior mesenteric which was mobilized just beyond the ligament of Treitz. The vessel here was very large and of good quality. There was no pulse in it. The left and right common iliac arteries were next dissected out through small openings in the retroperitoneal space. The tunneling pathway for the vein bypass graft to the celiac artery was carried out anterior and a little bit lateral to the aorta using digital pathway and completed with a Semb ligature carrier and umbilical tape. A small gonadal branch was clipped proximally and distally.
The patient was systemically heparinized after passing the graft, and the graft was then suture anastomosed to the celiac artery with the toe distal and the heel proximal. Backward flow through the vessel was modest. The vein was then appropriately trimmed, suture anastomosed to the left common iliac artery occluding the left common iliac distally with a Cooley and proximal with angled DeBakey. Double-armed 6-0 Prolene was used for this. The suture line was tested. Two reinforcing sutures of 5-0 Prolene were placed to seal gussets. Before flow was allowed to proceed, excellent bounding pulse was noted. The lie was good and the length was good. The orientation was proper.
After this, we turned attention to the superior mesenteric artery, which already had vessel loops in place. We then pulled up on these and were able to occlude the vessel distally. Proximally there was no flow. The side branches were occluded with silk Potts ties. Vessel was opened longitudinally. The suture line was placed with the toe proximal and the heel distal. The vein was then passed through an opening in the mesentery, and then underneath the mesenteric containing the inferior mesenteric artery and down onto the anterior aspect of the left common iliac artery where it was suture anastomosed with double-armed 5-0 Prolene suture. Flow was brisk. Backbleeding was noted coming from the superior mesenteric artery at the conclusion of the distal suture line but no forward bleeding was noted.
The Medi-Stim flow probe was brought up into the field, size 5 and used with gel to measure adequate flow in both bypass grafts prior to giving protamine. The activated-clotting time was tested and found to be over 200 seconds. Then 25 mg of protamine was given. Good clotting mechanism developed. The grafts were checked again with the handheld Dopplers and good signals were noted throughout. There is minimal redundancy of the left bypass graft to the celiac artery where it has a nice curving loop parallel to the left common iliac artery. The small bowel was run and noted to be quite a bit pinker than at the beginning of the case. The omentum was replaced in its normal configuration. A routine layered closure was completed. The methylcellulose sheets to prevent adhesions were placed. The estimated blood loss was 200 mL. Sterile dressings were applied. The patient was lifted and transported having tolerated the procedure nicely. Sponge and instrument count report was correct x2.
PREOPERATIVE DIAGNOSIS
Chronic mesenteric arterial insufficiency.
POSTOPERATIVE DIAGNOSIS
Chronic mesenteric arterial insufficiency.
OPERATIVE PROCEDURE
Celiac and superior mesenteric artery bypass for chronic mesenteric arterial insufficiency.
SURGEON
Dr. A. , MD
FIRST ASSISTANT
Dr. B., MD
SECOND ASSISTANT
Mr. C
ANESTHESIA
Dr. D.
SKIN PREP
Alcohol and DuraPrep.
FINDINGS
This is a XX female admitted to the hospital on XXXXX, with bleeding gastric ulcers. Completion of her workup revealed severe ongoing chronic mesenteric arterial insufficiency. The patient has food fear, intestinal angina, and weight loss for the past 11 months. The risks versus benefits of proceeding with bypass of the celiac and superior mesenteric arteries were discussed with the patient and her family. They wished to proceed.
DESCRIPTION OF PROCEDURE
Patient underwent satisfactory general endotracheal anesthesia. The skin was scrubbed, prepped and draped in sterile fashion. A time-out was held. Two greater saphenous veins were harvested from the groin to above the knee on both sides. The veins were prepared. Layers were closed over 2 Blake drains. Lower body bear hugger was applied in conjunction with the already positioned upper body bear hugger.
The laparotomy incision was made in the midline. Bookwalter was inserted. The triangular ligament of the liver was divided and a left lobe of the liver was gently retracted backwards to be able to expose the aorta. This was done through opening the crus of the diaphragm. The celiac artery was relatively long and has minimal pulsation flow and has a long segment before it bifurcates into the common hepatic and splenic. After mobilizing this vessel proximally and distally, attention was then turned to the superior mesenteric which was mobilized just beyond the ligament of Treitz. The vessel here was very large and of good quality. There was no pulse in it. The left and right common iliac arteries were next dissected out through small openings in the retroperitoneal space. The tunneling pathway for the vein bypass graft to the celiac artery was carried out anterior and a little bit lateral to the aorta using digital pathway and completed with a Semb ligature carrier and umbilical tape. A small gonadal branch was clipped proximally and distally.
The patient was systemically heparinized after passing the graft, and the graft was then suture anastomosed to the celiac artery with the toe distal and the heel proximal. Backward flow through the vessel was modest. The vein was then appropriately trimmed, suture anastomosed to the left common iliac artery occluding the left common iliac distally with a Cooley and proximal with angled DeBakey. Double-armed 6-0 Prolene was used for this. The suture line was tested. Two reinforcing sutures of 5-0 Prolene were placed to seal gussets. Before flow was allowed to proceed, excellent bounding pulse was noted. The lie was good and the length was good. The orientation was proper.
After this, we turned attention to the superior mesenteric artery, which already had vessel loops in place. We then pulled up on these and were able to occlude the vessel distally. Proximally there was no flow. The side branches were occluded with silk Potts ties. Vessel was opened longitudinally. The suture line was placed with the toe proximal and the heel distal. The vein was then passed through an opening in the mesentery, and then underneath the mesenteric containing the inferior mesenteric artery and down onto the anterior aspect of the left common iliac artery where it was suture anastomosed with double-armed 5-0 Prolene suture. Flow was brisk. Backbleeding was noted coming from the superior mesenteric artery at the conclusion of the distal suture line but no forward bleeding was noted.
The Medi-Stim flow probe was brought up into the field, size 5 and used with gel to measure adequate flow in both bypass grafts prior to giving protamine. The activated-clotting time was tested and found to be over 200 seconds. Then 25 mg of protamine was given. Good clotting mechanism developed. The grafts were checked again with the handheld Dopplers and good signals were noted throughout. There is minimal redundancy of the left bypass graft to the celiac artery where it has a nice curving loop parallel to the left common iliac artery. The small bowel was run and noted to be quite a bit pinker than at the beginning of the case. The omentum was replaced in its normal configuration. A routine layered closure was completed. The methylcellulose sheets to prevent adhesions were placed. The estimated blood loss was 200 mL. Sterile dressings were applied. The patient was lifted and transported having tolerated the procedure nicely. Sponge and instrument count report was correct x2.