What new connection is in the kasai procedure

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Reference no: EM133872870

Question

1. Read the operative report below and answer the questions that follow.

Preoperative Hyperbilirubinemia, suspected biliary atresia Diagnosis:

Postoperative Same

Diagnosis:

Procedure(s) Exploratory laparotomy, liver biopsy, portoenterostomy Kasai procedure Performed:

Specimens:

Findings:

Indications:

Details of Procedure:

Liver biopsies (wedge and core needle biopsies): gallbladder and biliary remnant

Gallbladder without a lumen appeared as fibrotic remnant. Anatomy consistent with biliary atresia. Jejunojejunostomy at approximately 15 cm from ligament of Treitz, roux limb approximately 35 to 40 cm in length.

The patient is a three-week-old female who was admitted to the hospital with hyperbilirubinemia. She had a HIDA scan that did not demonstrate any excretion of bile into the GI tract at 18 hours. We recommended an exployatory laparotomy, cholangiogram, liver biopsy, and possible portoenterostomy Kasai procedure. The indications, risks, and benefits of the procedure were discussed with her parents who agreed to proceed.

The patient was transported to the operating room and placed in a supine position on the operating room table. General anesthesia was initiated. The patient's abdomen was prepped and draped in the usual sterile fashion. A timeout was made in order to correctly identify the patient and the procedure performed.

A right subcostal incision was made with the scalpel. The subcutaneous tissues and fascia were divided with the electrocutery, and the abdominal cavity was entered safely. The liver was cholestatic appearing, but no evidence of cirrhosis: We identified where the gallbladder should be and there was just a fibrotic remnant. We mobilized the gallbladder remnant with the electrocutery and transected it. There was no identifiable lumen. We elected to abort an attempt at a cholangiogram and to proceed with a portoenterostomy. We continued the dissection of the gallbladder remnant down to the biliary tree remnant. The biliary tree remnant was dissected away from the hepatic arteries and portal vein. The biliary tree remnant was then suture ligated as it approached the duodenum with a 4-0 Vicryl suture ligature. The biliary tree remnant was then divided, leaving the suture on the remaining stump. We then continued the dissection up toward the portal plate. We fully dissected out the portal plate until a lattice-like structure was displayed. We fully excised the biliary tree remnant, and this was sent to Pathology. A thrombin-soaked piece of Gelfoam was placed over the portal plate. We then performed our liver biopsies. Near the falciform insertion there was a pedunculated portion of liver parenchyma. Two 2-0 chromic sutures were placed on either side of this segment. The segment was then excised with electrocutery. The two 2-0 chromic sutures were tied down over a piece of surgicel. We also obtained several passes with a Tru-Cut needle to obtain several core needle biopsies. The needle was passed through the same site on the capsule, and then direct pressure and a piece of surgicel was applied to the site. The liver biopsy specimens were sent to Pathology. We then prepared our roux limb and made our jejunojejunostomy. The ligament of Treitz was identified. We measured approximately 15 cm distal to the ligament of Treitz and divided the bowel with a firing of the 5 mm JustRight stapler. The distal staple line was oversewn with a 4-0 Vicryl suture. We then measured an additional 35 to 40 cm from our distal staple line, as this would comprise our roux limb, and performed an end-to-side jejunojejunostomy with interrupted 4-0 Vicryl sutures in a single-layer anastomosis. The mesenteric defect was also closed with interrupted 4-0 Vicryl sutures. The roux limb was brought up in a retro-colic fashion. The roux limb was tacked to the colonic mesentery where it passed with interrupted 4-0 Vicryl sutures to stabilize the limb and to close the defect. We made an enterostomy on our roux limb and performed a single layer anastomosis between our roux limb and portal plate in an end-to-side fashion with interrupted 5-0 PDS sutures. The fascia was then closed in two layers with running 2-0 Vicryl sutures. The skin was closed with a running 5-0 monocryl suture. The incision was anesthetized with 0.25% Marcaine. Dermabond and Steri-Strips were applied. The patient tolerated the procedure well without any apparent immediate complication. The patient was awakened from anesthesia and transported to PACU for recovery.

1. ???Is the exploratory laparotomy coded for this case? Why or why not?

2. What new connection is in the Kasai procedure?

3. Is the jejunojejunostomy coded separately?

4. What is the correct code assignment for this case?

Reference no: EM133872870

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