rgeib
Networker
Looking for advice re: the case below. I am not certain if 43281 is supported as a full dissection of the sac did not occur. would only 43653 be warranted with perhaps modifier 22 for the work that was done reducing the stomach back into the abdomen?
Thank you in advance for any advice.
Procedure(s): LAPAROSCOPIC ASSISTED REDUCTION OF HIATAL HERNIA 2. Laparoscopic assisted G-tube 3. EGD
The patient was brought in the operating room placed in supine position and given general anesthesia. After prepping and draping the abdomen in the standard fashion, supraumbilical 10 mm incision was made and the abdomen was entered with a direct open Hassan technique followed by insertion of a 12 mm port. Under direct vision another 12 and 2 5 motor ports were introduced into the abdomen epigastric 5 mm port was then replaced with a Nathanson liver retractor to retract the liver and expose the hiatal hernia.
A very large hiatal hernia was then exposed after placing the patient in reverse Trendelenburg position. With help of multiple graspers we were able to reduce three fourths of the stomach into the abdomen by hand overhand technique. There was significant amount of fundus still in the chest however as discussed preoperatively the intent of today's surgery was not to dissect the sac in the chest and spent another couple of hours doing a big surgery but to pexied the stomach laparoscopically to prevent any episodes of organoaxial or meso axial volvulus of the stomach.
We then did a EGD and identified the distal part of the stomach near the antrum. The stomach was inflated and the guidewire was then passed under laparoscopic vision into the anterior part of the stomach over a needle this guidewire was then grabbed endoscopically and pulled out through the mouth, a PEG tube was then attached and was pulled through the anterior abdominal wall by the assistant. Repeat endoscopy confirmed good position of the PEG. This was secured in the standard fashion. At this time all the ports were removed after removing the Nathanson liver retractor, the abdominal wall was injected with local anesthetic, the fascia at the supraumbilical site was closed with a figure-of-eight 0 Vicryl suture. The skin was closed with 4-0 Monocryl sutures. Dressing and local anesthetics were given, patient was then extubated and shifted to PACU in a stable condition, I performed the entire surgery along with the resident as dictated above. And I was present during the entire case.
Thank you in advance for any advice.
Procedure(s): LAPAROSCOPIC ASSISTED REDUCTION OF HIATAL HERNIA 2. Laparoscopic assisted G-tube 3. EGD
The patient was brought in the operating room placed in supine position and given general anesthesia. After prepping and draping the abdomen in the standard fashion, supraumbilical 10 mm incision was made and the abdomen was entered with a direct open Hassan technique followed by insertion of a 12 mm port. Under direct vision another 12 and 2 5 motor ports were introduced into the abdomen epigastric 5 mm port was then replaced with a Nathanson liver retractor to retract the liver and expose the hiatal hernia.
A very large hiatal hernia was then exposed after placing the patient in reverse Trendelenburg position. With help of multiple graspers we were able to reduce three fourths of the stomach into the abdomen by hand overhand technique. There was significant amount of fundus still in the chest however as discussed preoperatively the intent of today's surgery was not to dissect the sac in the chest and spent another couple of hours doing a big surgery but to pexied the stomach laparoscopically to prevent any episodes of organoaxial or meso axial volvulus of the stomach.
We then did a EGD and identified the distal part of the stomach near the antrum. The stomach was inflated and the guidewire was then passed under laparoscopic vision into the anterior part of the stomach over a needle this guidewire was then grabbed endoscopically and pulled out through the mouth, a PEG tube was then attached and was pulled through the anterior abdominal wall by the assistant. Repeat endoscopy confirmed good position of the PEG. This was secured in the standard fashion. At this time all the ports were removed after removing the Nathanson liver retractor, the abdominal wall was injected with local anesthetic, the fascia at the supraumbilical site was closed with a figure-of-eight 0 Vicryl suture. The skin was closed with 4-0 Monocryl sutures. Dressing and local anesthetics were given, patient was then extubated and shifted to PACU in a stable condition, I performed the entire surgery along with the resident as dictated above. And I was present during the entire case.