Does anyone have any input for codes for this op note?
PREOPERATIVE DIAGNOSIS:
Median arcuate ligament syndrome with compression of celiac artery with postprandial abdominal pain.
POSTOPERATIVE DIAGNOSIS:
Median arcuate ligament syndrome with compression of celiac artery with postprandial abdominal pain.
OPERATION PERFORMED:
1. Retroperitoneal exploration of intraabdominal aorta.
2. Revision of diaphragmatic crus.
3. Resection of median arcuate ligament with resection of periganglionic celiac structures.
DESCRIPTION OF OPERATION:
Placed in the supine position. General anesthesia administered. Antibiotics were given. A time-out was observed. A Foley catheter was placed. Pneumatic compression stockings were placed about the lower extremities. Abdominal cavity was prepped and draped in the usual manner with DuraPrep. An epigastric midline incision was made through which the abdominal cavity was entered. Entry into the abdomen was unencumbered. There was no scar. There were no adhesions. The lesser sac was identified. The Omni-Tract retractor was used to gain exposure. Utilizing a Thunderbeat ultrasonic cautery device the lesser sac was taken down taking care not to injure the gastric vasculature. The plane between the esophagus and the aorta was identified. The aorta was dissected down anteriorly along its surface. The right and the left crus were identified. The Thunderbeat was used to further mobilize the pylorus as well as the 1st portion of the duodenum to allow for more caudal traction to be placed on the structures to gain additional exposure. On preoperative CT scanning, the celiac appeared to arise at the base of the l1 vertebral. The retroperitoneum within the T12-L1 area had interwoven muscular structures from the right and the left crus that extended down over the aorta extensively. These was overly developed. They extended down and created generous right and left psoas musculature as well on the right and the left sides of the aorta respectively. Beginning at T12, the anterior surface of the aorta was cleared of these interdigitations of muscular structures working caudad. Upon entering the lower portion of L1 the celiac artery was still not well visualized. Due to concerns over placing too much tension across the lesser curvature of the stomach as well as the duodenum, the approach to the lesser sac was abandoned. The avascular plane between the gastrocolic ligament and the transverse colon was taken down again utilizing a Thunderbeat dissection device. The stomach, duodenum, omentum were swept cephalad again. The retroperitoneum was exposed with the Omni-Tract retractor. The previous point of dissection was identified and re-exposed. Dissection was then continued caudally. Again here there was a fibrinous band of structures anteriorly and just lateral to the aorta. All of this was freed along the midline working laterally to the right and left sides of the aorta respectively. Once the celiac trunk was identified, there did appear to be a dense fibrous network of ganglionic structures and ligament structures about the celiac artery. Working from the 4 o'clock to the 8 o'clock position, from the celiac artery with the 12 o'clock position being due cephalad, these structures were carefully and gently dissected away from the celiac artery. A specimen was obtained of the ganglionic structures. Small lymphatics were clipped with surgical clips and/or coagulated. There appeared to be now a good freeing of the celiac ostium and trunk for over a distance of approximately 1.5 cm. The SMA was not well visualized from this approach but on preoperative scanning the SMA was widely patent on CT as well as by duplex imaging. Once the celiac artery was freed again the retroperitoneum was reinspected. There was no undue bleeding noted from the aorta from T12 down to the mid vertebral body. L2 was freed and clear freeing the celiac trunk. Intraoperative fluoroscopy was obtained again to reidentify and confirm vertebral landmarks with regard to the aorta and the celiac trunk. Surgicel was placed about the retroperitoneum overlying the aorta. The stomach and omentum were allowed to return to their normal resting positions. The lesser sac was reinspected. Again there was no bleeding within the lesser sac. The liver also appeared to be unremarkable. The abdominal cavity was irrigated with GU irrigant. The area was evacuated. The midline celiotomy was then repaired utilizing double-stranded 1 PDS to reapproximate the fascia. Camper's and Scarpa's fascia were closed with 2-0 Monocryl and 3-0 Monocryl. The skin incision was closed with a running subcuticular 4-0 Monocryl and a sterile dressing was placed over the abdominal wound after Steri-Strips were placed over the incision. He tolerated well. No complications. He was extubated and transported from the operating room to the recovery room in stable condition. Prior to extubation, he did have his orogastric tube removed.
PREOPERATIVE DIAGNOSIS:
Median arcuate ligament syndrome with compression of celiac artery with postprandial abdominal pain.
POSTOPERATIVE DIAGNOSIS:
Median arcuate ligament syndrome with compression of celiac artery with postprandial abdominal pain.
OPERATION PERFORMED:
1. Retroperitoneal exploration of intraabdominal aorta.
2. Revision of diaphragmatic crus.
3. Resection of median arcuate ligament with resection of periganglionic celiac structures.
DESCRIPTION OF OPERATION:
Placed in the supine position. General anesthesia administered. Antibiotics were given. A time-out was observed. A Foley catheter was placed. Pneumatic compression stockings were placed about the lower extremities. Abdominal cavity was prepped and draped in the usual manner with DuraPrep. An epigastric midline incision was made through which the abdominal cavity was entered. Entry into the abdomen was unencumbered. There was no scar. There were no adhesions. The lesser sac was identified. The Omni-Tract retractor was used to gain exposure. Utilizing a Thunderbeat ultrasonic cautery device the lesser sac was taken down taking care not to injure the gastric vasculature. The plane between the esophagus and the aorta was identified. The aorta was dissected down anteriorly along its surface. The right and the left crus were identified. The Thunderbeat was used to further mobilize the pylorus as well as the 1st portion of the duodenum to allow for more caudal traction to be placed on the structures to gain additional exposure. On preoperative CT scanning, the celiac appeared to arise at the base of the l1 vertebral. The retroperitoneum within the T12-L1 area had interwoven muscular structures from the right and the left crus that extended down over the aorta extensively. These was overly developed. They extended down and created generous right and left psoas musculature as well on the right and the left sides of the aorta respectively. Beginning at T12, the anterior surface of the aorta was cleared of these interdigitations of muscular structures working caudad. Upon entering the lower portion of L1 the celiac artery was still not well visualized. Due to concerns over placing too much tension across the lesser curvature of the stomach as well as the duodenum, the approach to the lesser sac was abandoned. The avascular plane between the gastrocolic ligament and the transverse colon was taken down again utilizing a Thunderbeat dissection device. The stomach, duodenum, omentum were swept cephalad again. The retroperitoneum was exposed with the Omni-Tract retractor. The previous point of dissection was identified and re-exposed. Dissection was then continued caudally. Again here there was a fibrinous band of structures anteriorly and just lateral to the aorta. All of this was freed along the midline working laterally to the right and left sides of the aorta respectively. Once the celiac trunk was identified, there did appear to be a dense fibrous network of ganglionic structures and ligament structures about the celiac artery. Working from the 4 o'clock to the 8 o'clock position, from the celiac artery with the 12 o'clock position being due cephalad, these structures were carefully and gently dissected away from the celiac artery. A specimen was obtained of the ganglionic structures. Small lymphatics were clipped with surgical clips and/or coagulated. There appeared to be now a good freeing of the celiac ostium and trunk for over a distance of approximately 1.5 cm. The SMA was not well visualized from this approach but on preoperative scanning the SMA was widely patent on CT as well as by duplex imaging. Once the celiac artery was freed again the retroperitoneum was reinspected. There was no undue bleeding noted from the aorta from T12 down to the mid vertebral body. L2 was freed and clear freeing the celiac trunk. Intraoperative fluoroscopy was obtained again to reidentify and confirm vertebral landmarks with regard to the aorta and the celiac trunk. Surgicel was placed about the retroperitoneum overlying the aorta. The stomach and omentum were allowed to return to their normal resting positions. The lesser sac was reinspected. Again there was no bleeding within the lesser sac. The liver also appeared to be unremarkable. The abdominal cavity was irrigated with GU irrigant. The area was evacuated. The midline celiotomy was then repaired utilizing double-stranded 1 PDS to reapproximate the fascia. Camper's and Scarpa's fascia were closed with 2-0 Monocryl and 3-0 Monocryl. The skin incision was closed with a running subcuticular 4-0 Monocryl and a sterile dressing was placed over the abdominal wound after Steri-Strips were placed over the incision. He tolerated well. No complications. He was extubated and transported from the operating room to the recovery room in stable condition. Prior to extubation, he did have his orogastric tube removed.