codedog
True Blue
I have a question , I don't see the incisional hernia , I see the lengthen cpt code code 43338,and 43336 not sure on how to code this provider wants 49560, 43337, 49560, 43500 , but don't think its right , any help is appreciated
FINDINGS: Upon entering the peritoneal cavity, and a incisional hernia was noted at the previous packed to placement site. It was measured to be approximately 4 cm in diameter. Further exploration into the peritoneal cavity confirms presence of paraesophageal hiatal hernia recurrence with slipped Nissen fundoplication. Approximately 40% of the stomach was trapped in the hernia sac above the diaphragm.
ESTIMATED BLOOD LOSS: 60 mL
COMPLICATIONS: None
SPECIMEN: Fundus of the stomach
Implants: None
INDICATION: Recurrence of paraesophageal hiatal hernia with Nissen fundoplication.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, and underwent general anesthesia with orotracheal intubation. The patient was prepped and draped in the usual sterile manner. A time-out was taken to identify the patient as well as the purpose of the procedure. Upper midline incision was made extended up to the xiphoid process, and entered the peritoneal cavity in the usual fashion. Upon entering the peritoneal cavity the above findings were noted. After appropriate tractions were accomplished with Omni retractors in place, the left lobe was mobilized and detached from the diaphragm and cleared the area to visualize the entire stomach. The dissection was commenced at the junction of the crural repair, superior arch and extended laterally until the entire hernia sac was then freed and was able to bring down the GE junction below the diaphragm with fundoplication wrap in situ. During the dissection, gastrotomy was made and need to be repaired in 2 layers with 3 0 silk pop offs. Then further dissection was continued into the posterior aspect of the GE junction to on wrap the fundoplication. Once the GE junction was then brought down in place with completely detached from the posterior aspect, Penrose drain was placed for traction purposes. Further dissection of the adhesion in the hernia sac to mobilize the esophagus for more length. After noticing that the esophagus was too short, Colli's esophagoplasty was performed with 38 French bougie in place. The Eschleon laparoscopic reticulating stapler with green loads, 45 mm in length was used to create neo esophagus in the usual fashion. Then crura was repaired with pledgetted 2 0 Ethibond sutures. Upon complete repair of the crura, Toupe fundoplication was performed with a fixation of the portion of the wrap sutured to the crura with pledgetted 2 0 Ethibond sutures. Previous gastrostomy (peg) site was then mobilized and stapled off with 45 mm green load and further reinforced with 3 0 Lembert sutures. Once the crural repair, and fundoplication was completed, intraoperative EGD was performed to identify any leak. There was no evidence of any leak and the intraoperative EGD was acceptable. After copious irrigation, the bougie was removed and replaced with an NG tube in place and placed to suction. Then after instruments and lap counts were noted to be correct, incision was then injected with total of 100 mL of a mixture of Exparel, Marcaine and injectable saline, and closed the incision with 2 looped 0 PDS. The skin was skin stapled in the usual fashion and, sterile dressing was applied on top of it. During this entire procedure, the EBL was about 60 mL, and the patient tolerated well without any signs complication. The patient was later awakened, extubated and taken to recovery room for further recovery.
thanks
Trent
FINDINGS: Upon entering the peritoneal cavity, and a incisional hernia was noted at the previous packed to placement site. It was measured to be approximately 4 cm in diameter. Further exploration into the peritoneal cavity confirms presence of paraesophageal hiatal hernia recurrence with slipped Nissen fundoplication. Approximately 40% of the stomach was trapped in the hernia sac above the diaphragm.
ESTIMATED BLOOD LOSS: 60 mL
COMPLICATIONS: None
SPECIMEN: Fundus of the stomach
Implants: None
INDICATION: Recurrence of paraesophageal hiatal hernia with Nissen fundoplication.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, and underwent general anesthesia with orotracheal intubation. The patient was prepped and draped in the usual sterile manner. A time-out was taken to identify the patient as well as the purpose of the procedure. Upper midline incision was made extended up to the xiphoid process, and entered the peritoneal cavity in the usual fashion. Upon entering the peritoneal cavity the above findings were noted. After appropriate tractions were accomplished with Omni retractors in place, the left lobe was mobilized and detached from the diaphragm and cleared the area to visualize the entire stomach. The dissection was commenced at the junction of the crural repair, superior arch and extended laterally until the entire hernia sac was then freed and was able to bring down the GE junction below the diaphragm with fundoplication wrap in situ. During the dissection, gastrotomy was made and need to be repaired in 2 layers with 3 0 silk pop offs. Then further dissection was continued into the posterior aspect of the GE junction to on wrap the fundoplication. Once the GE junction was then brought down in place with completely detached from the posterior aspect, Penrose drain was placed for traction purposes. Further dissection of the adhesion in the hernia sac to mobilize the esophagus for more length. After noticing that the esophagus was too short, Colli's esophagoplasty was performed with 38 French bougie in place. The Eschleon laparoscopic reticulating stapler with green loads, 45 mm in length was used to create neo esophagus in the usual fashion. Then crura was repaired with pledgetted 2 0 Ethibond sutures. Upon complete repair of the crura, Toupe fundoplication was performed with a fixation of the portion of the wrap sutured to the crura with pledgetted 2 0 Ethibond sutures. Previous gastrostomy (peg) site was then mobilized and stapled off with 45 mm green load and further reinforced with 3 0 Lembert sutures. Once the crural repair, and fundoplication was completed, intraoperative EGD was performed to identify any leak. There was no evidence of any leak and the intraoperative EGD was acceptable. After copious irrigation, the bougie was removed and replaced with an NG tube in place and placed to suction. Then after instruments and lap counts were noted to be correct, incision was then injected with total of 100 mL of a mixture of Exparel, Marcaine and injectable saline, and closed the incision with 2 looped 0 PDS. The skin was skin stapled in the usual fashion and, sterile dressing was applied on top of it. During this entire procedure, the EBL was about 60 mL, and the patient tolerated well without any signs complication. The patient was later awakened, extubated and taken to recovery room for further recovery.
thanks
Trent
