Looking for a second coding opinion on the case below. Any help is greatly appreciated!
PROCEDURE: The patient was brought to the operating room, placed on the operating table
in the supine position. After introduction of general anesthesia, the abdomen was prepped
and draped in the sterile fashion. Veress needle was inserted in the left upper quadrant,
and the abdomen was insufflated with C02. A small incision was made in the paraumbilical area, and under direct vision of the camera scope using Visiport technique, the abdominal cavity was accessed. Upon accessing the abdominal cavity with the laparoscope, an additional 8-French robotic port was placed 12 em to the left of the camera port, and
using sharp and blunt dissections, multiple adhesions with inflammatory changes were carefully separated and taken down. Some further dense adhesions were taken down later and that will be provided further in the report. The abdomen contained a large amount of ascitic fluid, which was drained, approximately 5 L of ascites. Some of the fluid was
taken for Gram stain and amylase and lipase. Once that was accomplished, additional 2 robotic ports were placed, approximately 12-French ports from each side and a 12-French accessory port was also placed. The robotic system was brought into the field and docked according to the manufacturer specifications, and then, the instruments were introduced into the abdominal cavity. Assuming the position of the console, further dense adhesions were lysed using the EndoWrist sealer and Harmonic scalpel combination, and the anterior surface of the liver was reached. Upon lifting the left lobe of the liver, additional
fluid collection was drained under the left lobe of the liver which appears to be a self- limited collection containing sterile fluid. Intraoperative ultrasound was then performed, and the ultrasound of the anterior surface of the stomach revealed a large peripancreatic collection pushing the gastric wall anteriorly with partial compression of
the gastric wall. Once that was identified, using a Harmonic scalpel, a gastrostomy was
made, and the posterior wall of the stomach was exposed. Additional intraoperative ultrasound was performed and the position of the pseudocyst was clearly identified. Using ultrasound guidance and Harmonic scalpel, the posterior gastric wall was sectioned, and the cavity of the pseudocyst was entered, draining a large amount of peripancreatic fluid with debris. Additional debridement was performed, and some of the debris was sent for pathological examination. A large amount of pancreatic debris was evacuated from the
pseudocyst cavity, and postdebridement ultrasound demonstrated complete collapse of the pseudocyst and decrease in the amount of necrosis. Once that was accomplished, the posterior wall of the pseudocyst was stapled to the posterior wall of the stomach using
Endo GIA stapler from Covidien with purple reload and then, the edges of the pseudocyst
were also oversewn using 2-0 silk suture. Once that was accomplished, the gastric tube was positioned appropriately in the stomach and then the gastric wall was closed using Endo GIA stapler and then the staple line was oversewn using 2-0 PDS suture and then reinforced using 2-0 PDS in continuous fashion in Lambert style and imbricating the staple line. Once that was accomplished, the abdominal cavity was irrigated, suctioned, dried
out, and inspected for hemostasis. Once everything was found to be absolutely satisfactory, two 19-French channel drains were placed, one to the gastric staple line on the left closer to the lesser sac and anterior to the lesser omentum, and one in the right
pericolic gutter around the right lobe of the liver. Both drains were exited through 2 separate incisions on the trocars and were secured to the skin using 0 silk sutures. The robotic system was undocked and removed, and trocars were withdrawn one by one, and their sites were observed for bleeding. Once the umbilical trocar was removed, the abdominal cavity was deflated, the incisions on 12-French ports' fascia were closed using #1 Vicryl
in a figure-of-eight fashion, and all skin incisions were then closed using 4-0 Monocryl subcuticular suture. The patient tolerated the procedure well. There were no complications. He was transferred to the recovery room in stable condition.
PROCEDURE: The patient was brought to the operating room, placed on the operating table
in the supine position. After introduction of general anesthesia, the abdomen was prepped
and draped in the sterile fashion. Veress needle was inserted in the left upper quadrant,
and the abdomen was insufflated with C02. A small incision was made in the paraumbilical area, and under direct vision of the camera scope using Visiport technique, the abdominal cavity was accessed. Upon accessing the abdominal cavity with the laparoscope, an additional 8-French robotic port was placed 12 em to the left of the camera port, and
using sharp and blunt dissections, multiple adhesions with inflammatory changes were carefully separated and taken down. Some further dense adhesions were taken down later and that will be provided further in the report. The abdomen contained a large amount of ascitic fluid, which was drained, approximately 5 L of ascites. Some of the fluid was
taken for Gram stain and amylase and lipase. Once that was accomplished, additional 2 robotic ports were placed, approximately 12-French ports from each side and a 12-French accessory port was also placed. The robotic system was brought into the field and docked according to the manufacturer specifications, and then, the instruments were introduced into the abdominal cavity. Assuming the position of the console, further dense adhesions were lysed using the EndoWrist sealer and Harmonic scalpel combination, and the anterior surface of the liver was reached. Upon lifting the left lobe of the liver, additional
fluid collection was drained under the left lobe of the liver which appears to be a self- limited collection containing sterile fluid. Intraoperative ultrasound was then performed, and the ultrasound of the anterior surface of the stomach revealed a large peripancreatic collection pushing the gastric wall anteriorly with partial compression of
the gastric wall. Once that was identified, using a Harmonic scalpel, a gastrostomy was
made, and the posterior wall of the stomach was exposed. Additional intraoperative ultrasound was performed and the position of the pseudocyst was clearly identified. Using ultrasound guidance and Harmonic scalpel, the posterior gastric wall was sectioned, and the cavity of the pseudocyst was entered, draining a large amount of peripancreatic fluid with debris. Additional debridement was performed, and some of the debris was sent for pathological examination. A large amount of pancreatic debris was evacuated from the
pseudocyst cavity, and postdebridement ultrasound demonstrated complete collapse of the pseudocyst and decrease in the amount of necrosis. Once that was accomplished, the posterior wall of the pseudocyst was stapled to the posterior wall of the stomach using
Endo GIA stapler from Covidien with purple reload and then, the edges of the pseudocyst
were also oversewn using 2-0 silk suture. Once that was accomplished, the gastric tube was positioned appropriately in the stomach and then the gastric wall was closed using Endo GIA stapler and then the staple line was oversewn using 2-0 PDS suture and then reinforced using 2-0 PDS in continuous fashion in Lambert style and imbricating the staple line. Once that was accomplished, the abdominal cavity was irrigated, suctioned, dried
out, and inspected for hemostasis. Once everything was found to be absolutely satisfactory, two 19-French channel drains were placed, one to the gastric staple line on the left closer to the lesser sac and anterior to the lesser omentum, and one in the right
pericolic gutter around the right lobe of the liver. Both drains were exited through 2 separate incisions on the trocars and were secured to the skin using 0 silk sutures. The robotic system was undocked and removed, and trocars were withdrawn one by one, and their sites were observed for bleeding. Once the umbilical trocar was removed, the abdominal cavity was deflated, the incisions on 12-French ports' fascia were closed using #1 Vicryl
in a figure-of-eight fashion, and all skin incisions were then closed using 4-0 Monocryl subcuticular suture. The patient tolerated the procedure well. There were no complications. He was transferred to the recovery room in stable condition.
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