How would you go about coding this? I am at a complete loss.
Pre op diagnosis: slipped fundoplication, dysphagia
Post op diagnosis: same as above
Procedure performed:
Laparoscopic revision of paraesophageal hernia repair with gastropexy
Findings: half of stomach and Toupet fundoplication re-herniated through narrow cruroplasty, cruroplasty from prior surgery intact, dense adhesions between previous hernia sac and mediastinum,
Description of Procedure:
Patient was brought to the operating room and placed supine. He received general anesthesia and endotracheal intubation. The abdomen was prepped and draped in usual sterile fashion and IV antibiotics were given. A surgical pause was performed to confirm patient and procedure.
Existing 5mm supraumbilical incision was reopened and optical trocar entry technique used to enter the peritoneum using a 0 degree 5mm laparoscope. The abdomen was then insufflated to 15mmHg and camera swapped to 5mm 30 degree scope and direct visualization confirmed no injury to underlying structures. The same trocars were replaced through previous incisions: 12mm in the right upper quadrant, 5mm in the left upper, 5mm in the left lateral, and a stab incision in the subxiphoid position for the Nathanson liver retractor which was all placed under direct visualization without incident. Upon initial inspection it was apparent that the prior Toupet fundoplication and proximal stomach had slipped through the cruroplasty.
Attention was first turned toward the cruroplasty which was taken down in order to facilitate reduction of the stomach and fundoplication. The previously placed 0 v-loc sutures were cut with laparoscopic scissors and removed. The early adhesions between the stomach and mediastinum were then lysed with a combination of blunt dissection and bipolar energy via the Ethicon Enseal device. The fundoplication was also then released by cutting the previously placed Ethibond sutures in order to facilitate visualization and identification of anatomy. The herniated fundoplication and stomach was then circumferentially dissected out from the the mediastinum and this portion was performed with slow meticulous dissection to avoid injury to the surrounding pleura, pericardial tissue, and aorta. During this dissection a 1/4 inch penrose drain was placed as a handle to facilitate dissection. The hernia sac was then resected with the Enseal, removed via the 12mm trocar and disposed. The proximal esophageal dissection limit was reached and the esophageal length was reassessed. The stomach lay comfortably in the abdominal cavity at rest however there was short esophageal length of less than 3 cm. We discussed repair options at this point and given the patient's mental status and non compliance with post op instructions, we decided that he was at high risk for repeat hiatal herniation and performing a repeat fundoplication would result in significant dysphagia. We decided to forego performing a fundoplication at this time however the stomach would be fixated with a gastropexy to the diaphragm.
A posterior cruroplasty was then performed using a running 0 permanent STRATAFIX V-loc suture. The crura were healthy and robust. An anterior cruroplasty was also performed using one figure of eight 0 Ethibond suture to adequately approximate the hiatus around the esophagus. The Penrose drain was removed. A lateral gastropexy was then performed by suturing the proximal greater curvature and fundus to the left diaphragm using a running 0 Ethibond. The abdomen was irrigated and hemostasis was ensured. The liver retractor was then removed. The 12 mm port site fascia was reapproximated using an 0 Vicryl on a suture passer.
The abdomen was desufflated and the remaining ports were removed. The skin was reapproximated using 4-0 Monocryl and dressed with Dermabond.
All sponge and needle counts were correct at the end of the procedure x2.
Pre op diagnosis: slipped fundoplication, dysphagia
Post op diagnosis: same as above
Procedure performed:
Laparoscopic revision of paraesophageal hernia repair with gastropexy
Findings: half of stomach and Toupet fundoplication re-herniated through narrow cruroplasty, cruroplasty from prior surgery intact, dense adhesions between previous hernia sac and mediastinum,
Description of Procedure:
Patient was brought to the operating room and placed supine. He received general anesthesia and endotracheal intubation. The abdomen was prepped and draped in usual sterile fashion and IV antibiotics were given. A surgical pause was performed to confirm patient and procedure.
Existing 5mm supraumbilical incision was reopened and optical trocar entry technique used to enter the peritoneum using a 0 degree 5mm laparoscope. The abdomen was then insufflated to 15mmHg and camera swapped to 5mm 30 degree scope and direct visualization confirmed no injury to underlying structures. The same trocars were replaced through previous incisions: 12mm in the right upper quadrant, 5mm in the left upper, 5mm in the left lateral, and a stab incision in the subxiphoid position for the Nathanson liver retractor which was all placed under direct visualization without incident. Upon initial inspection it was apparent that the prior Toupet fundoplication and proximal stomach had slipped through the cruroplasty.
Attention was first turned toward the cruroplasty which was taken down in order to facilitate reduction of the stomach and fundoplication. The previously placed 0 v-loc sutures were cut with laparoscopic scissors and removed. The early adhesions between the stomach and mediastinum were then lysed with a combination of blunt dissection and bipolar energy via the Ethicon Enseal device. The fundoplication was also then released by cutting the previously placed Ethibond sutures in order to facilitate visualization and identification of anatomy. The herniated fundoplication and stomach was then circumferentially dissected out from the the mediastinum and this portion was performed with slow meticulous dissection to avoid injury to the surrounding pleura, pericardial tissue, and aorta. During this dissection a 1/4 inch penrose drain was placed as a handle to facilitate dissection. The hernia sac was then resected with the Enseal, removed via the 12mm trocar and disposed. The proximal esophageal dissection limit was reached and the esophageal length was reassessed. The stomach lay comfortably in the abdominal cavity at rest however there was short esophageal length of less than 3 cm. We discussed repair options at this point and given the patient's mental status and non compliance with post op instructions, we decided that he was at high risk for repeat hiatal herniation and performing a repeat fundoplication would result in significant dysphagia. We decided to forego performing a fundoplication at this time however the stomach would be fixated with a gastropexy to the diaphragm.
A posterior cruroplasty was then performed using a running 0 permanent STRATAFIX V-loc suture. The crura were healthy and robust. An anterior cruroplasty was also performed using one figure of eight 0 Ethibond suture to adequately approximate the hiatus around the esophagus. The Penrose drain was removed. A lateral gastropexy was then performed by suturing the proximal greater curvature and fundus to the left diaphragm using a running 0 Ethibond. The abdomen was irrigated and hemostasis was ensured. The liver retractor was then removed. The 12 mm port site fascia was reapproximated using an 0 Vicryl on a suture passer.
The abdomen was desufflated and the remaining ports were removed. The skin was reapproximated using 4-0 Monocryl and dressed with Dermabond.
All sponge and needle counts were correct at the end of the procedure x2.