herrera4
Guru
would this op note be a 44227? and what about the hernia repair-could that be coded separately?
This is a pleasant 75-year-old female known to me for perforated diverticulitis with end colostomy. Postoperatively she had some orthopaedic issues and had a long history of irritable bowel issues so she did not want to rush to take down her colostomy. She was seen in my office recently because of a parastomal hernia. In discussion the patient is willing to have her colostomy taken down with primary repair laparoscopically and repair of the parastomal hernia. She understands the risks and benefits of the surgery and signed consent for surgery. On the day of surgery she was brought to the operating room and general endotracheal anesthesia was administered. She was placed in lithotomy position. The abdomen was prepped and draped in the usual sterile fashion. A super umbilical incision was planned because of a low midline incision. This was anesthetized with 0.5% Marcaine with epinephrine. Incision was made with #15 blade and deeper tissue divided by electrocautery. The midline fascia was scored with electrocautery. The abdomen was entered under direct vision. Port was placed and the abdomen was insufflated. There were extensive midline omental adhesions. There were adhesions to the left colon as it went to the parastomal hernia and there were small bowel adhesions low in the pelvis. Two 5 mm right lateral ports were placed. A combination of sharp dissection and ligature dissection was used to remove the midline adhesions to the omentum. There was no significant small bowel in this region. Inferior to that there were dense small bowel adhesions to the anterior abdominal wall and these were taken down very carefully with endoscopic scissors. These were followed laterally and in fact these loops of small bowel were adherent to the left colon. The small bowel was removed from the left colon using the scissors. The small bowel adhesions to the pelvis were taken down very carefully with sharp dissection low in the pelvis in order to view the rectal stump. The two blue stitches at the end of the rectal stump were easily identified and the area was generally free from adhesions. The pelvis was generously irrigated and suctioned free. At this point it was felt that most of the small bowel adhesions were dealt with so that the colostomy could be taken down. The area around the left lower quadrant stoma was widely anesthetized with 0.5% Marcaine with epinephrine. An oval incision was made with the #10 blade. The abdomen and the parastomal hernia were immediately entered. Electrocautery was used to free the left colon from surrounding tissue. Eventually it was completed free of surrounding tissue. The adhesions to the left sidewall from the left colon were taken down with the Metzenbaum scissors as far as they could through this incision. The descending colon was occluded with the bowel clamp. The distal end was removed with the electrocautery. The sizers were passed. It was felt that a 28 mm staple would be appropriate for anastomosis. The anvil was brought to the field. A pursestring of 3-0 Prolene was placed in the seromuscular tissue of the end of the colostomy. The anvil was then pursestringed into place. The more superficial surface of the colon was then marked with a blue pen. The laparoscopic hand port was then brought to the field and placed through the parastomal hernia site and the abdomen was re-insufflated. The colon appeared to reach easily into the pelvis so Dr.xxx went down to the perineum. There was some very hard concretions of fecal tissue that were removed from the rectum upon entry of the rigid sigmoidoscope. Once the area was free of fecal material the colon sizer/dilators were passed through the rectum and they easily passed to the end of the rectal stump so the 28 mm EEA stapler was easily advanced into place. At this point I advanced the stapler into place. The spike was advanced to the previous staple line under direct vision. It was in good position. The anvil was then easily passed into the spike. The stapler was closed and fired without incident. Upon removing the stapler the anastomotic donuts were intact. The anastomosis was tested under saline irrigation and occlusion with insufflation through the rigid sigmoidoscope and there was no leakage of air. There appeared to be a small amount of tension on the anastomosis so attention was brought to the left colon and as it attached to the side wall this was taken down sharply under direct vision. This provided much more flexibility to the descending colon as it approached the anastomosis. The area was generously irrigated and suctioned free. There were some dense small bowel adhesions to the left lower quadrant that was going behind the descending colon. As these were mobilized more small bowel was herniated behind the colon so that these adhesions to the left lower quadrant were taken down sharply and the small bowel was then reduced to the right side of the colon. The results were satisfactory.
The pelvis was irrigated and suctioned free. 10 cc of Tisseel fibrin sealant were sprayed over the anastomosis. There was no bleeding noted. Sponge, needle, and instrument counts were all correct. The ports were all taken out under direct vision. The parastomal hernia site was closed vertically with full thickness #1 Prolene stitch. The super umbilical port site was closed with interrupted figure-of-eight 0 Vicryl stitch and all skin incisions were closed with staples. The patient tolerated the procedure well and was brought to the Recovery Room in satisfactory condition.
Thanks for any help!
This is a pleasant 75-year-old female known to me for perforated diverticulitis with end colostomy. Postoperatively she had some orthopaedic issues and had a long history of irritable bowel issues so she did not want to rush to take down her colostomy. She was seen in my office recently because of a parastomal hernia. In discussion the patient is willing to have her colostomy taken down with primary repair laparoscopically and repair of the parastomal hernia. She understands the risks and benefits of the surgery and signed consent for surgery. On the day of surgery she was brought to the operating room and general endotracheal anesthesia was administered. She was placed in lithotomy position. The abdomen was prepped and draped in the usual sterile fashion. A super umbilical incision was planned because of a low midline incision. This was anesthetized with 0.5% Marcaine with epinephrine. Incision was made with #15 blade and deeper tissue divided by electrocautery. The midline fascia was scored with electrocautery. The abdomen was entered under direct vision. Port was placed and the abdomen was insufflated. There were extensive midline omental adhesions. There were adhesions to the left colon as it went to the parastomal hernia and there were small bowel adhesions low in the pelvis. Two 5 mm right lateral ports were placed. A combination of sharp dissection and ligature dissection was used to remove the midline adhesions to the omentum. There was no significant small bowel in this region. Inferior to that there were dense small bowel adhesions to the anterior abdominal wall and these were taken down very carefully with endoscopic scissors. These were followed laterally and in fact these loops of small bowel were adherent to the left colon. The small bowel was removed from the left colon using the scissors. The small bowel adhesions to the pelvis were taken down very carefully with sharp dissection low in the pelvis in order to view the rectal stump. The two blue stitches at the end of the rectal stump were easily identified and the area was generally free from adhesions. The pelvis was generously irrigated and suctioned free. At this point it was felt that most of the small bowel adhesions were dealt with so that the colostomy could be taken down. The area around the left lower quadrant stoma was widely anesthetized with 0.5% Marcaine with epinephrine. An oval incision was made with the #10 blade. The abdomen and the parastomal hernia were immediately entered. Electrocautery was used to free the left colon from surrounding tissue. Eventually it was completed free of surrounding tissue. The adhesions to the left sidewall from the left colon were taken down with the Metzenbaum scissors as far as they could through this incision. The descending colon was occluded with the bowel clamp. The distal end was removed with the electrocautery. The sizers were passed. It was felt that a 28 mm staple would be appropriate for anastomosis. The anvil was brought to the field. A pursestring of 3-0 Prolene was placed in the seromuscular tissue of the end of the colostomy. The anvil was then pursestringed into place. The more superficial surface of the colon was then marked with a blue pen. The laparoscopic hand port was then brought to the field and placed through the parastomal hernia site and the abdomen was re-insufflated. The colon appeared to reach easily into the pelvis so Dr.xxx went down to the perineum. There was some very hard concretions of fecal tissue that were removed from the rectum upon entry of the rigid sigmoidoscope. Once the area was free of fecal material the colon sizer/dilators were passed through the rectum and they easily passed to the end of the rectal stump so the 28 mm EEA stapler was easily advanced into place. At this point I advanced the stapler into place. The spike was advanced to the previous staple line under direct vision. It was in good position. The anvil was then easily passed into the spike. The stapler was closed and fired without incident. Upon removing the stapler the anastomotic donuts were intact. The anastomosis was tested under saline irrigation and occlusion with insufflation through the rigid sigmoidoscope and there was no leakage of air. There appeared to be a small amount of tension on the anastomosis so attention was brought to the left colon and as it attached to the side wall this was taken down sharply under direct vision. This provided much more flexibility to the descending colon as it approached the anastomosis. The area was generously irrigated and suctioned free. There were some dense small bowel adhesions to the left lower quadrant that was going behind the descending colon. As these were mobilized more small bowel was herniated behind the colon so that these adhesions to the left lower quadrant were taken down sharply and the small bowel was then reduced to the right side of the colon. The results were satisfactory.
The pelvis was irrigated and suctioned free. 10 cc of Tisseel fibrin sealant were sprayed over the anastomosis. There was no bleeding noted. Sponge, needle, and instrument counts were all correct. The ports were all taken out under direct vision. The parastomal hernia site was closed vertically with full thickness #1 Prolene stitch. The super umbilical port site was closed with interrupted figure-of-eight 0 Vicryl stitch and all skin incisions were closed with staples. The patient tolerated the procedure well and was brought to the Recovery Room in satisfactory condition.
Thanks for any help!
