Could someone please help me in finding a cpt code for "Diagnostic laparoscopy with the unwrapping of the anterior fundoplication and drainage of the abdominal and thoracic fluid"
Here is op notes.
DETAILS OF PROCEDURE:
The patient was brought to the operating room and placed on the operating table. General anesthesia was administered and the patient was successfully orally intubated. The appropriate identification of the patient and the operation was performed with the surgeon, anesthesia and operating room nursing staff present. The patient's prophylactic antibiotic was confirmed to be given during this period of identification. The abdomen was prepped and draped in a sterile fashion.
The prior incisions were used. I used a Veress needle at the right perimedian incision to gain access to the abdominal cavity. The pneumoperitoneum was created. A 5 mm trocar was placed at this site under direct equalization. Inspection revealed no injury at the point of access. The other trochars were placed without difficulty. The Nathanson liver retractor was inserted through an epigastric incision. The liver was retracted to expose the area of the esophageal hiatus. Patient had significant adhesions and reaction from the prior surgery. The anterior fundoplication was done as the suture was divided. This did not appear to be the cause of the patient's obstruction. There was severe reactionary adhesions at the esophageal hiatus.
I performed a flexible endoscopy. The endoscope was inserted and advanced down under his goals patient. The esophagus was normal. The proximal stomach had a significant compression but no other abnormalities were identified. The endoscope could be passed through this region with very minimal resistance. The remaining portion of the stomach was normal. I felt the proximal stomach was still under compression and therefore partially obstructed.
I returned to the operation with new sterile gown and gloves. Blunt and sharp dissection was performed at the hiatus to identify the left and right crus. Along the proximal lesser curve purulent fluid was encountered. This region was washed out and cultures were taken through a Lukens trap. The esophagus appeared to be freed from the esophageal hiatus and additional purulent fluid was encountered superior to the left crus. I felt the area of the obstruction had been relieved.
I went to the head of bed and performed a flexible endoscopy without difficulty. The esophagus was normal. The prior area of compression now was quite distensible and the endoscope was passed without resistance. The area of the esophageal hiatus and the proximal stomach was submerged under irrigation. There were no air bubbles to suggest any injury to the esophagus or stomach. The stomach was decompressed and the irrigation was suctioned out. From the right paramedian incision, a 19 French Hemovac drain was placed near the esophageal hiatus. The Nathanson liver retractor was removed without difficulty. The pneumoperitoneum was decompressed and all trochars were removed. The drain was surgically adhered to the skin with a Prolene suture. All skin incisions were reapproximated with subcuticular suture and a glue. All instruments and sponge counts were correct at the end the operation. The patient was transferred to the recovery area in stable condition.
Thanks for your help with this.
Here is op notes.
DETAILS OF PROCEDURE:
The patient was brought to the operating room and placed on the operating table. General anesthesia was administered and the patient was successfully orally intubated. The appropriate identification of the patient and the operation was performed with the surgeon, anesthesia and operating room nursing staff present. The patient's prophylactic antibiotic was confirmed to be given during this period of identification. The abdomen was prepped and draped in a sterile fashion.
The prior incisions were used. I used a Veress needle at the right perimedian incision to gain access to the abdominal cavity. The pneumoperitoneum was created. A 5 mm trocar was placed at this site under direct equalization. Inspection revealed no injury at the point of access. The other trochars were placed without difficulty. The Nathanson liver retractor was inserted through an epigastric incision. The liver was retracted to expose the area of the esophageal hiatus. Patient had significant adhesions and reaction from the prior surgery. The anterior fundoplication was done as the suture was divided. This did not appear to be the cause of the patient's obstruction. There was severe reactionary adhesions at the esophageal hiatus.
I performed a flexible endoscopy. The endoscope was inserted and advanced down under his goals patient. The esophagus was normal. The proximal stomach had a significant compression but no other abnormalities were identified. The endoscope could be passed through this region with very minimal resistance. The remaining portion of the stomach was normal. I felt the proximal stomach was still under compression and therefore partially obstructed.
I returned to the operation with new sterile gown and gloves. Blunt and sharp dissection was performed at the hiatus to identify the left and right crus. Along the proximal lesser curve purulent fluid was encountered. This region was washed out and cultures were taken through a Lukens trap. The esophagus appeared to be freed from the esophageal hiatus and additional purulent fluid was encountered superior to the left crus. I felt the area of the obstruction had been relieved.
I went to the head of bed and performed a flexible endoscopy without difficulty. The esophagus was normal. The prior area of compression now was quite distensible and the endoscope was passed without resistance. The area of the esophageal hiatus and the proximal stomach was submerged under irrigation. There were no air bubbles to suggest any injury to the esophagus or stomach. The stomach was decompressed and the irrigation was suctioned out. From the right paramedian incision, a 19 French Hemovac drain was placed near the esophageal hiatus. The Nathanson liver retractor was removed without difficulty. The pneumoperitoneum was decompressed and all trochars were removed. The drain was surgically adhered to the skin with a Prolene suture. All skin incisions were reapproximated with subcuticular suture and a glue. All instruments and sponge counts were correct at the end the operation. The patient was transferred to the recovery area in stable condition.
Thanks for your help with this.