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Code This!

Scenario Week of September 07, 2011:
View Current Scenario

Operative Report: Laparoscopic repair of hiatal hernia

Laparoscopic fundoplication

Laparoscopic-assisted gastrostomy tube



Diagnosis: Gastroesophageal reflux

Hiatal hernia

History of aspiration

Malnutrition

Traction sutures were placed on either side of the umbilicus. A small transverse transumbilical incision was made. A Veress needle was passed and position confirmed with 360 degree rotation as well as a saline drop test.

The abdomen was insufflated to a pressure of 15 mmHg Co2. A 3 mm trocar was placed and secured at the skin with silk sutures. The camera was placed and the abdomen was inspected. A right upper quadrant incision was made using direct visualization and local anesthesia, and a 5 mm liver retractor without a trocar was placed. We positioned the liver out of the way then placed a right and left abdominal trocar and a left lateral trocar, all were 3 mm, using local anesthesia and direct visualization. The left upper quadrant trocar will be used for the gastrostomy tube site. Using these ports, we retracted the stomach to the right side and took down the short gastrics. The left crura was identified and the fibers were dissected off to identify it. Attention was turned to the right side of the esophagus, and we took down the gastrohepatic ligament with electrocautery and took down the phrenoesophageal ligament bluntly. This created a retroesophageal space. A 30-French bougie was used to guide the dissection. Once this space was identified, a hiatal hernia was identified even though we did minimal dissection.

With the bougie placed, 2-0 silk suture x2 was used to close down the hiatal hernia. During the dissection, we made sure to keep the vagus nerves approximated to the esophagus. We then passed the stomach through the retroesophageal space, ensuring that it was not twisted. Then the fundoplication was created incorporating the GE junction. We performed a wrap using 2-0 silks, incorporating 2 stitches into the esophagus at the 10 o’clock position. The wrap was approximately 2 cm in length. The bougie was removed.

Attention was then turned to creating the G-tube through the left upper quadrant port. After grasping a portion of the stomach on the greater curvature away from the pylorus, a 0 PDS was passed through a transabdominal stay-suture in a cranial and caudal position relative to where the stomach was grasped. We then released the grasper and removed the trocar. Anesthesia insufflated the stomach with 90 mL of air. Under direct visualization, we passed the needle through this incision site and into the stomach between the 2 sutures, watching the stomach desufflate, confirming intragastric position. We passed a wire then sequentially dilated the gastrotomy up to 16-French. At this point, the 1.2 cm, 12-French gastrostomy tube was placed over the wire into the stomach and 5 mL was instilled in the balloon. It appeared to be intragastric. This was confirmed later by instilling fluid and watching gastric contents return. Transabdominal sutures were tied loosely over the G-tube. Then the liver retractor and all the trocars were removed under direct visualization. The pneumoperitoneum was released through the umbilicus and the umbilical fascia was approximated with 3-0 PDS, using a grooved director. All wounds were closed with Dermabond.

Assign ICD-9-CM diagnosis and procedure codes.


Diagnoses
530.81 Esophageal reflux

263.9 Unspecified protein-calorie malnutrition (CC)

553.3 Diaphragmatic hernia

Procedures
44.67 Laparoscopic procedures for creation of esophagogastric sphincteric competence

53.71 Laparoscopic repair of diaphragmatic hernia, abdominal approach

43.19 Other gastrostomy

Rationale

The initial reason for surgery was to correct the patient’s gastroesophageal reflux disease (GERD) and insert a gastrostomy tube for feeding to correct the patient’s malnutrition; therefore, the GERD should be the principal diagnosis. Using 263.9 (malnutrition) as principal diagnosis would result in an “unrelated principal diagnosis” surgical MS-DRG (981–989), which are targets for regulatory agencies. The hernia was found incidentally during the procedure.

The fundoplication and hernia repair were performed via laparoscope as separate procedures and both should be reported. The hernia repair was performed via ports made in the transumbilical and right upper quadrant abdominal regions. Lastly, the gastrostomy tube insertion was not percutaneous but laparoscopically assisted and should be reported using 43.19 Other gastrostomy.

 
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