Q&A Reconstruction of Abdominal Wall and ~~~

[DiCamille]

Hello ~

This one is driving me insane! Not sure if this would be the sort of topic that I can suggest for a Thursday night CCO Special or if I should just crawl under my desk and hide until I can figure it out. I've actually crawled under my desk for a couple of days now, to be honest. So, now I turn to you.

This is the "Operative Procedure" listed on the Op Report:
Exploratory laparotomy w/extensive (over 2 hour) adhesiolysis w/reconstruction of the abdominal wall using a transversus abdominal released technique w/reinforcement w/a Physiomesh intraparietal mesh, repair of small bowel enterotomy, and abdominoplasty.

If this is not a forum friendly topic, is there a service provided by CCO for coding on an op-report by op-report basis for a fee? Or maybe some sort of coding bundle pricing structure? Does CCO provide that type of service? I cannot seem to locate it ~ forgive my inability to find it if it is there?!?!! I have utilized an online coding site's on-demand coding service and have not been happy w/their customer service at all, unfortunately.

Thank you so much for your guidance in this crazy, fabulous world of ours!!!! It's comforting to have you leading the way and staying by our side.

Diane

 

[Laureen]

Hi Diane,

We don't have a coding service per se. We try to help out here via the discussion board. Can you paste the body of the report here as well (redacted of course)

 

[DiCamille]

Hi Diane,

We don't have a coding service per se. We try to help out here via the discussion board. Can you paste the body of the report here as well (redacted of course)

Hello Laureen ~

Thanks for such a speedy response! Here we go~

OPERATIVE FINDINGS:
The patient had a large incisional hernia. She had multiple incisional hernias repaired about 10 years ago with a Marlex onlay. At the time of this surgery, she had a large defect extending from the subxiphoid area above the pubis, which basically consisted of just a Marlex mesh, which was encapsulated overlying, very thinned out, and attenuated abdominal wall consisting really of just scar tissue and peritoneum. In addition, she had extensive adhesions involving many loops of small bowel adhesed to itself as well as to the abdominal wall.

DESCRIPTION OF PROCEDURE:
Under general anesthesia, the patient was prepped and sterilely draped. Previous long midline scar was excised, exposing the underlying subcutaneous tissue. Just deep to this was the Marlex mesh, which was basically overlying just peritoneum. After excising the skin scar, we then opened up the mesh and got access to the peritoneal cavity. We then embarked on a very tedious 2 hour adhesiolysis dissecting multiple loops of small bowel from the anterior abdominal wall fascia so that we could ultimately perform marked transverse abdominis release. I made a tiny enterotomy and a loop of small bowel in the left mid abdomen and this was immediately repaired with a TA 30 staple line. There was another serosal tear closely adjacent to the enterotomy and this was likewise repaired by using a TA 30 stapler. Another questionable serosal tear was repaired with 3-0 seromuscular Vicryl sutures. After I noted a very tedious 2-hour dissection, we had to dissect the adhesed small bowel from the the anterior abdominal wall fascia as far laterally as the mid clavicular line on either side of the abdominal wall. We then excised the transverse abdominis layer from the rectus sheath on the left of the midline and took this as far laterally as the posterior axillary line from the xiphoid down to the pubis. This was a very difficult dissection as the layers were fused together and it was not as easy as usual, developing this plane, we then did the same dissection separating transverse abdominis fascia from the rectus sheath on the right side in a similar fashion. We had enough laxity at this point to close the layer on itself and we sutured the posterior sheath together with a running 0 PDS suture. Thus, we sutured from the xiphoid down to the pubis. It should be noted that down in the pelvis, there were several loops of small bowel that was stuck to the bladder and we could not safely excise these loops off of the bladder without certainly making enterotomies and possibly also hole in the bladder, so that we did the best we could, but then decided to leave these loops in place unless we have a problem on our hands. After closing the posterior sheath, we then used a 30 x 30 cm piece of Physiomesh, which we then laid over the posterior sheath between it and the rectus fascia and an anterior sheath and then tacked it laterally to the abdominal wall using absorbable tacks. This we did circumferentially in the left and right. We then closed the anterior sheath in the midline over the mesh with a running looped PDS, as we got inferiorly , there was really no anterior fascia to close over the mesh, so we did the best we could, but there was mesh exposed. We used interrupted 0 PDS and did the best we can to close fascia over the mesh, but there was some mesh exposed at this level. We used a biological glue between the anterior sheath and the mesh and also placed two 19 mm Blake drains on either in the right and left gutters. We did this prior to closing the entire anterior sheath. A strip of skin and subcutaneous tissue to the right of the midline measuring approximately 15 x 4 cm was excised for cosmetic reasons to also _____ as there was laxity down the abdominal wall following reduction of the hernia. We then closed the subcutaneous tissue and sutured it to the anterior fascia with interrupted 3-0 Vicryl. Skin itself was closed with running 4-0 Vicryl in subcuticular fashion, drains were sutured in place with 3-0 nylon. The patient tolerated the procedure well and left the operating room in good condition.

Thank you so much for looking at this Laureen. Your help is appreciated beyond words!