Surgery

With the patient in the supine position under general anesthesia, the abdomen was sterilely prepped and draped in the usual fashion. A transverse incision was made about 18 cm from the xiphoid just to the left of the midline, 12 mm in length. A Visiport was used to pass a 12 mm port and insufflate with CO2. Five mm ports were placed in the subxyphoid, in the left anterior axillary subcostal area and on the right anterior axillary subcostal area and perhaps 3-4 cm below the line between the midline and the right upper quadrant 5 mm port.

I placed a 15 mm port and with these ports in place, I was able to first identify the cecum and run the small bowel to 300 cm from the ileocecal valve, and there I placed 2 endoclips distally and 1 proximally. Then I lifted it up to the area of the duodenum and when I could document that it was going to reach, I proceeded to drop it and place a liver retractor and dissect out the duodenum and 4 cm distal to the pylorus.

I transected it with a tan load staple. I took most of the soft tissue and vasculature on the cephalad side with a Sonicision, which allowed it to drop down to meet the ileum. I then brought the ileum up after transecting the duodenum and I used a 2-0 Vicryl to secure the stapled edge of the duodenum to the edge of the ileum in continuity with an EndoStitch. Then I opened both the duodenum and the ileum with the Sonicision.

I secured the anastomosis with a running 3-0 Vicryl and an outer layer of a running 2-0 Vicryl was then added. We closed the Peterson space with this ileum with a running 2-0 Ethibond. We completed the procedure with the sleeve and 6 cm from the pylorus on the greater curvature, we began a dissection and transection of all of the blood vessels on the greater curvature up to the GE junction. I then utilized the Endo-GIA black staple for the antrum after having the 34-French EZ tube placed by the anesthesiologist passed to the pylorus and using that as a rough gauge, we transected the stomach rather loosely to the edge of the EZ tube. I then used a purple staple and then finally tan staples until we were done.

We removed the stomach through an EndoCatch tube bag through the right upper quadrant 15 mm port, which was then closed with an inlet of 0 Vicryl suture. The area was irrigated and lavaged as was the duodenal area and the EZ tube was withdrawn and the CO2 was allowed to escape. The wounds were then lavaged and closed with staples. The patient tolerated the procedure fairly well.

ICD-10 PCS code assignment:

0DB64Z3 Excision of stomach, percutaneous endoscopic approach, vertical
0D194ZB Bypass duodenum to ileum, percutaneous endoscopic approach

Rationale:

Per coding clinic 2Q 2016 page 31 “Laparoscopic biliopancreatic diversion with duodenal switch” This surgery has two parts. In the first part, the volume of the stomach is reduced by dividing it vertically and removing approximately 85%. The stomach and pyloric nerves are still intact and the stomach is functional. The remaining stomach is banana-shaped and has less capacity. In the second part, the digestive juices, and bile and pancreatic juice are re-routed (bypassed) from the duodenum to the ileum, minimizing calorie absorption. Assign the following ICD-10-PCS codes:

0DB64Z3 Excision of stomach, percutaneous endoscopic approach, vertical
0D194ZB Bypass duodenum to ileum, percutaneous endoscopic approach, for the BPD with duodenal switch

Root operation Excision “Cutting out or off without replacement a portion of a body part”

Root operation Bypass “Altering the route of passage of the contents of a tubular body part”

Explanation:

They remove or excise all but a sleeve portion of the stomach. Then they transect a portion of the duodenum and form an anastomosis to the ileum creating a duodeno-ileum bypass.

References

  • Centers for Medicare and Medicaid Services. “ICD-10-PCS Official Guidelines for Coding and Reporting 2017”
  • American Hospital Association. Coding Clinic® for ICD-10-CM and ICD-10-PCS

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