posted by T Simmons .
I have tried to read and understand this question, however I just had eye surgery,and to be honest, I just can not see to read the code book.~~~
PREOPERATIVE DIAGNOSIS: Morbid obesity.
POSTOPERATIVE DIAGNOSIS: Same.
1. Laparoscopic Roux-en-Y gastrointestinal bypass.
2. Liver biopsy.
INDICATION: The patient is a 36-year-old female who presents with morbid obesity, with a current BMI of 46.0. She has gone to the seminars, and we have discussed laparoscopic Roux-en-Y gastrointestinal bypass along with the risk of surgery including bleeding, infection, leakage from the anastomoses, conversion to open procedure, postoperative stenoses of the anastomoses, or bowel obstruction. She understands and wishes to proceed.
PROCEDURE: The patient was brought to the operating room and placed under general anaesthesia. A Foley catheter and orogastric tubes were inserted. She was prepped and draped sterilely with Betadine solution. A supraumbilical incision was made with a #15 blade, and dissection was carried down through the subcutaneous tissues bluntly. The patient had an incisional hernia from an old trocar port site. We placed our operative trocar into the abdomen, insufflated the abdomen. There was no damage to the underlying viscera. Under direct vision, we then placed two, midclavicular line, 12-millimeter ports that were just lateral and above the umbilical port. There was a right upper quadrant 12-millimeter port in the anterior axillary line and a left upper quadrant 5-millimeter port in the anterior axillary line. These were all placed under direct vision with no damage to the bowel. The patient had some adhesions of her gastrohepatic ligament to the liver. We took these down using the harmonic scalpel. Before continuing, a needle specimen was obtained from the liver, appropriately marked for pathologic evaluation. We then entered the retrogastric space and placed our taut catheter behind the stomach. We then flipped the omentum up over the top of itself. We elevated the transverse colon and opened the transverse colon where we could see the drain. We identified the ligament of Treitz and fired an Endo-GIA stapler across the bowel, down from the ligament of Treitz. We fired an additional load across the mesentery. We then counted out 100 centimeters of bowel and then performed a stapled side-to-side functional end-to-end anastomosis by opening the bowel on the proximal and distal sides with the harmonic scalpel, firing two loads of the Endo-GIA stapler and closing the anastomosis with an Endo-GIA fired staple line. This gave us a nice anastomosis. We closed the mesenteric defect here with an Ethibond suture and fixed with Laparoties. We then sutured the proximal end to the catheter and flipped the mesentery back down. We then brought the bowel and the catheter up in retrogastric fashion. Next, we identified the angle of His. We opened the angle of His, and we fired five loads of the Endo-GIA stapler across the stomach. We had blown up the 20-cc balloon and had about a 20-cc pouch. Once we had completely transected the stomach, we went above and placed the Bioenteric catheter within the gastric pouch. We passed the snare through it. We made a separate stab incision in the upper abdomen and passed the wire through. We then fed the anvil end of the CEA-21 stapler down through the back of the pharynx down through the esophagus and brought out through our gastric pouch. We then enlarged the left midclavicular line, abdominal port, and placed the CEA-25 stapler through here. We opened the staple line on the bowel that we had brought up after we had removed the taut catheter and placed the CEA stapler into the bowel, brought the spike through, connected the two ends of the CEA, closed it, and fired it. This gave us a nice 21-millimeter circular anastomosis. We completed the anastomosis with the Endo-GIA stapler. We imbricated the staple line with two Ethibond sutures, placed a wad of fat over the last to adhere the fat near our staple line. We tested the anastomosis with air with the bowel clamped, and there was no evidence of a leak. We then placed Hemaseel over this anastomosis, and then once again mobilized the mesentery. We then closed the mesenteric defect where the small bowel had gone in retrogastric fashion with the Ethicon Endo-suture. We once again placed Hemaseel on our small anastomosis. We placed 10 flat Jackson-Pratt drains near our GJ anastomosis, which came on out the left side. We removed the trocar ports under direct vision. We then extended our umbilical incision and reduced the umbilical hernia. We closed the fascial defect with interrupted 0 Prolene sutures. We anesthetized the wounds at all areas with a total of 60 cc of 0.50% Sensorcaine with epinephrine solution. We secured the drains in place with 0 silk sutures and then closed the skin with 3-0 Prolene sutures. Steri-Strips and sterile Band-Aids were applied. All sponge and needle counts were correct. We left the taut catheter and a Penrose drain in the left midclavicular line incision. All sponge and needle counts were correct. She tolerated this well and was taken to recovery in stable condition.
ICD-9-CM Codes: ____________, ____________, ____________