here is the OP note:
Indications for Surgery:
Pt has a longstanding history of Crohn disease. She has had a longstanding chronic rectovaginal fistula and perianal fistulas and developed adenocarcinoma involving the fistula tracts and a rectal cancer. Originally when she was diagnosed she was recommended to undergo neoadjuvant therapy for this. She did undergo neoadjuvant chemoradiation therapy. After completing the radiation therapy should have difficulty with significant distention forming and inability to eat without pain and significant drainage from the fistula. We therefore admitted her started her on some TPN. This allowed her to recover some nutrition and fluid balance with the TPN. She developed ascites during this time. She was recommended to undergo exploration, possible abdominoperineal resection with possible hysterectomy and bilateral salpingo- oophorectomy with perineal floor reconstruction for the rectal cancer. Risks, benefits, and alternatives were discussed at length with her. She understood and wished to proceed.
Surgeons Narrative:
Estimated Blood Loss: 500 cubic centimeters for portion of the procedure.
Drains: Four round Blake drains, one placed transabdominally in the pelvis and one placed transperineal in the pelvis and two placed in the right thigh.
Operative Procedure: The patient was brought in the operative room and placed in the operating room table in supine position. General endotracheal anesthesia was induced and large bore intravenous were placed. She was placed in modified lithotomy position using Allen stirrups and two rolls were placed underneath lumbar and sacral spine. We then prepped her abdomen both right and left sides and her perineum completely into the field. After this was completely prepped into the filed, a Foley catheter was placed sterilely as part of the abdominal field. Procedural pause was then performed confirming the patient's identity of the procedure performed, administration of intravenous antibiotics and subcu heparin. The patient did have an epidural placed prior to coming into the operating room by anesthesia. Midline incision was then made starting through her old midline incision, which went from the xiphoid process down the pubic bone. We entered the abdomen in the upper abdomen and did find a large amount of ascites 2 liters of ascites returning off that was evidence of carcinomatosis with significant peritoneal studding from her tumor. She did have an obstruction down in the pelvis involving the rectum and did have a rectovaginal fistula, but the mass is not fixed in the pelvis. It was involving the uterus and the ovaries. We initiated our dissection along the left paracolic gutter. She had majority of her colon artery resected and only had a small portion of approximately foot of colon going down to her rectum coming off an ileocolic anastomosis. We identified the left ureter and the right ureter and mobilized some along her entire length down to the pelvic floor. We were able to freed them from the overlying cancer and scar tissue. We then were also able to free the uterus from the anterior wall of the vagina then isolated the uterus and ovaries and fallopian tubes. We first clamped and isolated the ovarian artery and vein doubly ligating this with 2- 0 silk ties. The peritoneal attachments were divided and then the round ligament was isolated. Again on both the right and left sides ensuring that the ureters were out of harm's way and clamped and ligated. We dissected the ureters laterally on both sides and then isolated the uterine arteries at their base, where they entered the uterus. These were both clamped and ligated with 0 silk ties. They were doubly ligated. The patient because of the radiation therapy had significant degeneration of her cervix basically there was very little bleeding when isolating the cervix and then the cervix was divided just superiorly, which we divided the uterus just superiorly to the cervix using the electrocautery. A 0 Vicryl sutures were then placed to close the tissue at this level. Great care was taken not to incorporate the ureters. At completion the uterus was out with the ovaries and tubes and the ureters were kept out of harm's way. We then entered the presacral space and continued our dissection down and circumferentially dissected performing a total mesorectal excision down to the pelvic floor. We divided the mesentery to the colon identifying the superior what appeared to be superior hemorrhoidal artery clamping and ligating it with 2-0 silk ties doubly ligating it and using LigaSure device and divide the mesentery up to the ileum. We resected approximately 5 cm to the ileum and then divided by dividing the mesentery with a LigaSure and then divided the bowel with GIA 80 stapler. Once we had done a circumferential dissection down to the pelvic floor, we had mobilized the majority of the posterior wall of the vagina off the rectum.
We then went from below. There was good hemostasis from above. The Bookwalter retractor was removed. The legs were raised and Lone Star retractor was sutured to the perineum. We effaced the anus using Lone Star retractor and the vagina and then performed a circumferential incision around the anal muscles incorporating just the perineal body, which is where the rectovaginal fistula was present. We dissected down posteriorly first entering the peritoneal cavity between the coccyx and the rectum. On entering the cavity, we then divided the levator muscles with the electrocautery both on the right and left side. We did extend up through the vaginal wall clamping perineal artery coming off to the vulva posteriorly at this point on both right and left side. These were suture ligated with 2-0 Vicryl suture ligatures and 2-0 silk ties. We had then entered our previously dissected space between the rectum and the vagina and divided the distal most part of the vaginal cuff using electrocautery.
When the specimen was out, it was taken out and one complete specimen. There was good hemostasis posteriorly and laterally. Several bleeding points were oversewn along the pelvic musculature floor. We then irrigated with 3 liters of sterile saline and obtained hemostasis in the pelvis as well and then contacted Dr. S from Plastic Surgery. After discussion with myself it would be best to reconstruct the perineum with a right vastus lateralis flap from the right thigh. He will dictate this separately. While she was mobilizing the flap and positioning it and closing the perineal defect, we placed a #19- French round Jackson-Pratt drain in the pelvis through left lateral stab wound and secured the skin with 2-0 nylon suture. Similarly because of her carcinomatosis, we felt best to perform a gastrostomy. A 0 silk suture was then placed in a pursestring with a second one placed and after further pursestring out lateral from the first. It encompass the first pursestring. After these have been placed a gastrotomy was made. A 20-French 30 cubic centimeters balloon Foley catheter was brought through a left lateral stab wound incision on the skin, where it was felt the stomach to the anterior abdominal wall. It was then placed in the gastrostomy and the two pursestring sutures were placed and were secured after the balloon had been insufflated with 20 cubic centimeters of sterile water. A 3-0 silk suture was placed posteriorly to tack the stomach up to the intraabdominal wall. Similarly 3-0 silk sutures were placed medially and laterally through the gastrostomy to tack to the anterior abdominal wall and the 0 silk sutures were then used anteriorly and posteriorly that we kept the needles on to tack up to the intraabdominal completion. The gastrostomy tube was tacked up nicely to the intraabdominal wall and irrigated and flushed and easily irrigated and drained easily. It was attached to the skin with two 2-0 nylon sutures. We then slightly divided the mesentery to the small bowel further with a LigaSure device to facilitate formation of end ileostomy. She had been previously marked in the right lower quadrant. Discus skin was excised. Electrocautery dissection was continued down to the anterior rectus sheath, which was then incised. The muscle was split. Posterior rectus sheath and peritoneum were incised. The ileum was then brought out with its correct orientation after ensuring there was complete hemostasis. It was left in position there. We then again ensured hemostasis. We closed the anterior midline fascia with two running #1 Prolene sutures and secured above the umbilicus. Wound was irrigated and closed with interrupted staples. We then formatted a Brooke ileostomy using 3-0 Vicryl sutures to mature the stoma. At completion, it was protruding approximately centimeter from the intraabdominal wall was viable and edematous. Digital examination revealed no obstruction at the fascial liver. The abdominal wall had been cleaned and dried and dressing have been placed over the incision before maturing the stoma. Stoma appliance was then placed over the ileostomy bag. The patient's abdominal wall was further cleaned and dried. Dr. S then completed his portion of the procedure. The patient was then take off lithotomy position and returned to the supine position and transferred to recovery room in stable condition. Sponge, instrument, and needle count were correct at the completion of my portion of the procedure
Doctor is trying to bill 45110 and 58180. I dont agree with 45110. But i am not sure what code would fit the scenario better.
I'd greatly appreciate any opinion!
-D