does anyone have any suggestions? 
My dr did a laparoscopic total gastrectomy with extended lymphadenectomy & roux en y gastrojejunostomy. There is no laparoscopic gastric code that will work for this. They are all bariatric surgery related. but being that this is a medicare patient & they don't recognize unlisted codes, i am hoping someone has an idea.....
This patient had surgery due to gastric adenocarcinoma. i have attached a redacted report:
POSTOPERATIVE DIAGNOSES:
Gastric adenocarcinoma and giant hiatal hernia.
OPERATION PERFORMED:
Laparoscopic total gastrectomy with extend lymphadenectomy and Roux-en-Y esophagojejunostomy.
DESCRIPTION OF THE PROCEDURE:
After obtaining informed consent, the patient was brought to the Operating Room and placed on the operating table in the supine position. After induction of adequate general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion. A timeout was performed to confirm the patient's identity, the planned procedure, and that all required equipment and personnel were assembled. Laparoscopic access was obtained at the umbilicus using a Veress needle technique. Five additional laparoscopic ports were placed under direct vision. The greater omentum was elevated and starting at the hepatic flexure, the greater omentum was raised off of the transverse colon across the region of the middle colic range and then up to the splenic flexure. At the splenic flexure, the splenocolic ligament was divided using the LigaSure device and the omentum was thereby completely freed up from all attachments except to the stomach. The omentum was retracted to the left side and the short gastric vessels were divided using the LigaSure device as they entered the spleen and the gastrosplenic ligament was separated from the spleen and kept intact with the stomach. A Snowden-Pencer Diamond-Flex retractor was deployed from the epigastric port site; however, it was noted that due to the large size of the patient's liver, adequate retraction could not be achieved. An additional port site was placed to the left lower quadrant and from this additional port site adequate visualization could not be achieved. Retractor was placed through the left upper quadrant port site and from this vantage point, it was obvious that the patient had an extremely large hiatal hernia. The stomach was grasped and retracted downward. Pars flaccida was identified and entered. The gastrohepatic ligament was divided along the surface of the liver so that it would remain attached to the stomach. The area that had been previously tattooed with India ink was clearly visible slightly cephalad to the incisura of the stomach. The hiatal hernia sac was reduced out of the mediastinum along with the cardia of the stomach and the esophageal attachments to the mediastinum were taken down using blunt dissection and LigaSure until the esophagus was able to reach all the way into the abdominal cavity. The hiatal hernia was extremely large enough to admit a softball size amount of the stomach. However, with extensive esophageal dissection, enough esophagus could reach down into the abdomen. At this point, due to the prior endoscopy, I felt that the gastrectomy could be performed distal to the takeoff of the left gastric artery and the left gastric lymph nodes were dissected upwards and off of the vessel and the entry point of the left gastric artery and the lesser curve of the stomach was clearly visible. The lesser curve vascular arcade was stapled and divided inferior to left gastric artery with a 30-mm gray Endo-GIA stapler. Three firings of an Endo-GIA 60 purple were utilized to create pouch distal to the takeoff of the left gastric artery. The stomach was now completely divided from a small gastric pouch. Pulling the stapler, however, I noted that the tissue was extremely thick and I was concerned that there was tumor within the area of the staple line. There were a few retrogastric attachments that remained. These were taken down with the LigaSure device. A 6 cm incision was made inferior to the umbilicus in the midline over the suprapubic region using a knife and with cautery down to the fascia. The fascia was divided. An Alexis wound protector was placed through the incision. The gastric specimen was retrieved through the Alexis device and placed on the back table. I noted at that time that by palpation, the tumor was unacceptably close to the proximal resection margin and I feared that because the tissue was thick in that region that I was actually stapling through tumor. At this point, I changed my decision to leave a portion of the stomach and decided to perform a total gastrectomy. The stomach was passed off the field after I discussed orientation of the specimen with the pathologist. The lower midline incision was closed with a running looped #1 Maxon suture. The skin was left open. Pneumoperitoneum was reinstated. Laparoscopic instruments were introduced back into the abdomen. Two stay sutures were placed on either side of the esophagus. The pouch was elevated and the left gastric vessels were stapled and divided at their origin using a 30 gray Endo-GIA stapler. The stomach just distal to the gastroesophageal junction was selected and using a 60 mm purple Endo-GIA stapler, the proximal stomach was amputated leaving approximately 1 cm of the stomach left upon which to anastomose the small bowel. Specimen was placed in an EndoCatch bag for removal at the end of the case. The transverse colon was then elevated and the ligament of Treitz was identified. Small bowel was run for 30 cm where it was stapled and divided using an Endo-GIA stapler with a 60 mm tan load. The mesentery was serially divided using the Sonicision and the LigaSure device. Distal bowel was run for a distance of 65 cm. At that point 65 cm distal was brought alongside the tip of the biliopancreatic limb. An enterotomy was made in each limb using cautery and a 60 mm tan Endo-GIA stapler was introduced from the right side. One jaw of the stapler was advanced through each enterotomy. The stapler was closed and fired creating a side-to-side anastomosis. The common enterotomy was closed with a running 2-0 Surgidac suture placed in a Connell fashion. The mesenteric defect between the biliopancreatic limb and the Roux limb was closed with a running 2-0 Surgidac suture. An additional 3 cm incision was made in the left upper quadrant using an 11 blade knife. The OrVil stapler was selected. A size 25 was utilized. The nasogastric tube attached to the OrVil bell was advanced through the mouth by the anesthesia provider, Dr. ______. The small pouch was observed from within and when the OrVil stapler reached the posterior aspect at the targeted anastomosis, it was advanced slightly so that the tissue tinted outward. Cautery was used to create an opening there. As the nasogastric tube came through the pouch, the nasogastric tube was grasped by a wavy grasper and the tube was pulled through the stomach and out the mouth, such that the bell of the stapling device was now contained within the pouch. The sutures between the nasogastric tube and the bell were cut with laparoscopic scissors and the tube was extracted from the abdomen, leaving the bell device in place. The 3 cm incision in the left upper quadrant was matured with cautery and blunt dissection and the size 28 EEA stapler was advanced through the opening in the skin into the abdominal cavity. The tip of the Roux limb was selected and opened extensively using the Sonicision. Once the Roux limb was completely opened, it was dilated using a bowel clamp so that it would receive the end of the EEA stapler. The end of the EEA stapler was advanced into the Roux limb and the spike of the EEA stapler was advanced through the wall of the Roux limb. The spike of the stapler was placed into the bell device until the 2 portions clicked together indicating that they were secured. The stapler was then closed until the indicator was green and then fired creating an end-to-side esophagojejunostomy anastomosis. The stapler was removed and two intact donuts were set on the back table. The end of the Roux limb which was opened for admission of the stapler was now stapled and divided using a 60 mm tan Endo-GIA stapler. The EGD scope was advanced through the mouth into the distal esophagus and into the esophagojejunostomy anastomosis. The anastomosis was irrigated until under water and vigorous insufflation was provided via the endoscope as the bowel was clamped with a bowel clamp. There was noted to be bubbling from the posterior aspect of the anastomosis. Excess fluid was aspirated using the suction irrigator. The endoscope was pulled back into the distal esophagus. The anastomosis was carefully inspected and there was an area that was not securely stapled shut where the leak had been demonstrated. This opening was then closed with a running 2-0 Vicryl suture. Once this was completed, the anastomosis was again tested by clamping the proximal Roux limb and irrigating the anastomosis until it was under water. The EGD scope was advanced and vigorous insufflation was applied until air exited the mouth. At this time, there was no bubbling constituting a negative leak test. Excess fluid was aspirated using a suction irrigator. The patient's extremely large hiatal hernia was now addressed. Relaxing incisions were made on the crura on both left and right sides using the Sonicision device. Relaxing incisions were started as well as possible and extended upward. The posterior left and right crura were then approximated with 2-0 Surgidac figure-of-eight sutures. There was noted to be ample space anteriorly and the anastomosis was noted to be within the abdomen with approximately 3 cm of intraabdominal esophagus. At this point, I weighed the option of attaching the defect in the crura on the left and right side. I felt that a fresh anastomosis after such a vigorous dissection in the vicinity of biologic mesh was not prudent and I felt that the chance that the patient would develop diaphragmatic hernias on either side of the close crura was small enough that the placement of biologic mesh was not justified. The abdomen was carefully inspected for evidence of hemorrhage or bowel injury, neither were discovered. There was an area of the transverse colon, which was slightly discolored and I felt that it this would certainly remain viable and opted not to resect this region. A final sponge, needle, and instrument count was correct. The second remnant of the Roux limb and the proximal stomach were removed via the EndoCatch bag through the left upper quadrant port site that had been used for the EEA stapler. Pneumoperitoneum was released and each of the laparoscopic ports were removed. Each of the 12 mm port sites were closed at the level of fascia with interrupted 0 Vicryl suture. Each of the skin sites and skin in the lower midline was closed with surgical staples. A final needle, and instrument count was correct. Sterile dressings were applied. It was noted at this time that the patient had swelling of his upper torso and head and his face and crepitus of the tissue consistent with subcutaneous emphysema which was undoubtedly caused by the extensive hiatal dissection and several hours of surgery and carbon dioxide pneumoperitoneum. The anesthesiologist, Dr. ___________, related that there had been a few episodes of increased pulmonary pressures throughout the case. I knew there was no pneumothorax because the diaphragms remained in normal configuration throughout the case; however, I was concerned that with the degree of subcutaneous emphysema that the patient may have respiratory difficulty. Therefore, we elected to keep the patient intubated overnight until the subcutaneous emphysema would resolve from normal ventilation. The patient was therefore transferred to the Recovery Room in good condition.
MATERIAL FORWARDED TO PATHOLOGY:
Portion of jejunum, proximal stomach and left gastric artery and subtotal gastrectomy with extended lymphadenectomy specimen.
My dr did a laparoscopic total gastrectomy with extended lymphadenectomy & roux en y gastrojejunostomy. There is no laparoscopic gastric code that will work for this. They are all bariatric surgery related. but being that this is a medicare patient & they don't recognize unlisted codes, i am hoping someone has an idea.....
This patient had surgery due to gastric adenocarcinoma. i have attached a redacted report:
POSTOPERATIVE DIAGNOSES:
Gastric adenocarcinoma and giant hiatal hernia.
OPERATION PERFORMED:
Laparoscopic total gastrectomy with extend lymphadenectomy and Roux-en-Y esophagojejunostomy.
DESCRIPTION OF THE PROCEDURE:
After obtaining informed consent, the patient was brought to the Operating Room and placed on the operating table in the supine position. After induction of adequate general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion. A timeout was performed to confirm the patient's identity, the planned procedure, and that all required equipment and personnel were assembled. Laparoscopic access was obtained at the umbilicus using a Veress needle technique. Five additional laparoscopic ports were placed under direct vision. The greater omentum was elevated and starting at the hepatic flexure, the greater omentum was raised off of the transverse colon across the region of the middle colic range and then up to the splenic flexure. At the splenic flexure, the splenocolic ligament was divided using the LigaSure device and the omentum was thereby completely freed up from all attachments except to the stomach. The omentum was retracted to the left side and the short gastric vessels were divided using the LigaSure device as they entered the spleen and the gastrosplenic ligament was separated from the spleen and kept intact with the stomach. A Snowden-Pencer Diamond-Flex retractor was deployed from the epigastric port site; however, it was noted that due to the large size of the patient's liver, adequate retraction could not be achieved. An additional port site was placed to the left lower quadrant and from this additional port site adequate visualization could not be achieved. Retractor was placed through the left upper quadrant port site and from this vantage point, it was obvious that the patient had an extremely large hiatal hernia. The stomach was grasped and retracted downward. Pars flaccida was identified and entered. The gastrohepatic ligament was divided along the surface of the liver so that it would remain attached to the stomach. The area that had been previously tattooed with India ink was clearly visible slightly cephalad to the incisura of the stomach. The hiatal hernia sac was reduced out of the mediastinum along with the cardia of the stomach and the esophageal attachments to the mediastinum were taken down using blunt dissection and LigaSure until the esophagus was able to reach all the way into the abdominal cavity. The hiatal hernia was extremely large enough to admit a softball size amount of the stomach. However, with extensive esophageal dissection, enough esophagus could reach down into the abdomen. At this point, due to the prior endoscopy, I felt that the gastrectomy could be performed distal to the takeoff of the left gastric artery and the left gastric lymph nodes were dissected upwards and off of the vessel and the entry point of the left gastric artery and the lesser curve of the stomach was clearly visible. The lesser curve vascular arcade was stapled and divided inferior to left gastric artery with a 30-mm gray Endo-GIA stapler. Three firings of an Endo-GIA 60 purple were utilized to create pouch distal to the takeoff of the left gastric artery. The stomach was now completely divided from a small gastric pouch. Pulling the stapler, however, I noted that the tissue was extremely thick and I was concerned that there was tumor within the area of the staple line. There were a few retrogastric attachments that remained. These were taken down with the LigaSure device. A 6 cm incision was made inferior to the umbilicus in the midline over the suprapubic region using a knife and with cautery down to the fascia. The fascia was divided. An Alexis wound protector was placed through the incision. The gastric specimen was retrieved through the Alexis device and placed on the back table. I noted at that time that by palpation, the tumor was unacceptably close to the proximal resection margin and I feared that because the tissue was thick in that region that I was actually stapling through tumor. At this point, I changed my decision to leave a portion of the stomach and decided to perform a total gastrectomy. The stomach was passed off the field after I discussed orientation of the specimen with the pathologist. The lower midline incision was closed with a running looped #1 Maxon suture. The skin was left open. Pneumoperitoneum was reinstated. Laparoscopic instruments were introduced back into the abdomen. Two stay sutures were placed on either side of the esophagus. The pouch was elevated and the left gastric vessels were stapled and divided at their origin using a 30 gray Endo-GIA stapler. The stomach just distal to the gastroesophageal junction was selected and using a 60 mm purple Endo-GIA stapler, the proximal stomach was amputated leaving approximately 1 cm of the stomach left upon which to anastomose the small bowel. Specimen was placed in an EndoCatch bag for removal at the end of the case. The transverse colon was then elevated and the ligament of Treitz was identified. Small bowel was run for 30 cm where it was stapled and divided using an Endo-GIA stapler with a 60 mm tan load. The mesentery was serially divided using the Sonicision and the LigaSure device. Distal bowel was run for a distance of 65 cm. At that point 65 cm distal was brought alongside the tip of the biliopancreatic limb. An enterotomy was made in each limb using cautery and a 60 mm tan Endo-GIA stapler was introduced from the right side. One jaw of the stapler was advanced through each enterotomy. The stapler was closed and fired creating a side-to-side anastomosis. The common enterotomy was closed with a running 2-0 Surgidac suture placed in a Connell fashion. The mesenteric defect between the biliopancreatic limb and the Roux limb was closed with a running 2-0 Surgidac suture. An additional 3 cm incision was made in the left upper quadrant using an 11 blade knife. The OrVil stapler was selected. A size 25 was utilized. The nasogastric tube attached to the OrVil bell was advanced through the mouth by the anesthesia provider, Dr. ______. The small pouch was observed from within and when the OrVil stapler reached the posterior aspect at the targeted anastomosis, it was advanced slightly so that the tissue tinted outward. Cautery was used to create an opening there. As the nasogastric tube came through the pouch, the nasogastric tube was grasped by a wavy grasper and the tube was pulled through the stomach and out the mouth, such that the bell of the stapling device was now contained within the pouch. The sutures between the nasogastric tube and the bell were cut with laparoscopic scissors and the tube was extracted from the abdomen, leaving the bell device in place. The 3 cm incision in the left upper quadrant was matured with cautery and blunt dissection and the size 28 EEA stapler was advanced through the opening in the skin into the abdominal cavity. The tip of the Roux limb was selected and opened extensively using the Sonicision. Once the Roux limb was completely opened, it was dilated using a bowel clamp so that it would receive the end of the EEA stapler. The end of the EEA stapler was advanced into the Roux limb and the spike of the EEA stapler was advanced through the wall of the Roux limb. The spike of the stapler was placed into the bell device until the 2 portions clicked together indicating that they were secured. The stapler was then closed until the indicator was green and then fired creating an end-to-side esophagojejunostomy anastomosis. The stapler was removed and two intact donuts were set on the back table. The end of the Roux limb which was opened for admission of the stapler was now stapled and divided using a 60 mm tan Endo-GIA stapler. The EGD scope was advanced through the mouth into the distal esophagus and into the esophagojejunostomy anastomosis. The anastomosis was irrigated until under water and vigorous insufflation was provided via the endoscope as the bowel was clamped with a bowel clamp. There was noted to be bubbling from the posterior aspect of the anastomosis. Excess fluid was aspirated using the suction irrigator. The endoscope was pulled back into the distal esophagus. The anastomosis was carefully inspected and there was an area that was not securely stapled shut where the leak had been demonstrated. This opening was then closed with a running 2-0 Vicryl suture. Once this was completed, the anastomosis was again tested by clamping the proximal Roux limb and irrigating the anastomosis until it was under water. The EGD scope was advanced and vigorous insufflation was applied until air exited the mouth. At this time, there was no bubbling constituting a negative leak test. Excess fluid was aspirated using a suction irrigator. The patient's extremely large hiatal hernia was now addressed. Relaxing incisions were made on the crura on both left and right sides using the Sonicision device. Relaxing incisions were started as well as possible and extended upward. The posterior left and right crura were then approximated with 2-0 Surgidac figure-of-eight sutures. There was noted to be ample space anteriorly and the anastomosis was noted to be within the abdomen with approximately 3 cm of intraabdominal esophagus. At this point, I weighed the option of attaching the defect in the crura on the left and right side. I felt that a fresh anastomosis after such a vigorous dissection in the vicinity of biologic mesh was not prudent and I felt that the chance that the patient would develop diaphragmatic hernias on either side of the close crura was small enough that the placement of biologic mesh was not justified. The abdomen was carefully inspected for evidence of hemorrhage or bowel injury, neither were discovered. There was an area of the transverse colon, which was slightly discolored and I felt that it this would certainly remain viable and opted not to resect this region. A final sponge, needle, and instrument count was correct. The second remnant of the Roux limb and the proximal stomach were removed via the EndoCatch bag through the left upper quadrant port site that had been used for the EEA stapler. Pneumoperitoneum was released and each of the laparoscopic ports were removed. Each of the 12 mm port sites were closed at the level of fascia with interrupted 0 Vicryl suture. Each of the skin sites and skin in the lower midline was closed with surgical staples. A final needle, and instrument count was correct. Sterile dressings were applied. It was noted at this time that the patient had swelling of his upper torso and head and his face and crepitus of the tissue consistent with subcutaneous emphysema which was undoubtedly caused by the extensive hiatal dissection and several hours of surgery and carbon dioxide pneumoperitoneum. The anesthesiologist, Dr. ___________, related that there had been a few episodes of increased pulmonary pressures throughout the case. I knew there was no pneumothorax because the diaphragms remained in normal configuration throughout the case; however, I was concerned that with the degree of subcutaneous emphysema that the patient may have respiratory difficulty. Therefore, we elected to keep the patient intubated overnight until the subcutaneous emphysema would resolve from normal ventilation. The patient was therefore transferred to the Recovery Room in good condition.
MATERIAL FORWARDED TO PATHOLOGY:
Portion of jejunum, proximal stomach and left gastric artery and subtotal gastrectomy with extended lymphadenectomy specimen.
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