I was hoping someone would have input on coding this surgery. I don't believe there is a code for oversew of anastomotic leak and I believe that would be the main CPT in this case which included:
1. Exploratory laparotomy with extensive lysis of adhesions of approx 3 hours. (separate procedure)
2. Repair and oversew of an anastomotic leak.
3. Small bowel resection and repair of enterotomy x2. (which according to another thread in this forum, should not be coded out at all) - but I'm not sure if that is true in this case because it seems to be less of physician error and more of patient's body being so fragile.
Please advise
INDICATIONS: The patient is approximately 2 weeks out from a subtotal colectomy with ileorectal anastomosis for a synchronous colon cancer. He was admitted the night before with an abdominal wound infection and subsequently began having stool from his incision.
PROCEDURE FINDINGS: Small anastomotic leak in the anterior portion of the ileorectal anastomosis. He also had significant intraabdominal adhesions and basically a frozen abdomen with extensive firbrosis.
DESCRIPTION OF PROCEDURE: A previous midline incision was opened and carried into the abdominal cavity. Upon entering the abdominal cavity, we encountered a moderate amount of free enteric contents mostly located in the left lower quadrant. This was suctioned clear and then irrigated with copious amounts of normal saline. At this point, extensive lysis of adhesions was done which was very difficult and took approximately 3 hours to clearly identify where the anastomotic leak was. During that time period, we had 2 enterotomies and multiple serosal tears and it was almost impossible to clearly identify the proximal an distal bowel. After ultimately mobilizing the proximal bowel where the enterotomy was made in the left upper quadrant, this required a side-to-side stapled anastomosis to repair the enterotomy with a small bowel resection of approximately 3 inches. This was done with a GIA-75 stapler and a TA 55 stapler. there was also another mid-jejunal enterotomy that was made with a significant deserosalization, which required a functional end-to-end side-to-side anastomosis. At this point, further dissection proved to be virtually impossible due to any type of dissection resulting in extensive serosal tears.
At this point, a rigid sigmoidoscope was placed into the rectum after frog-legging the patient, and air was instilled into the rectum and the small anastomotic leak was identified in the anterior portion of the ileorectal anastomosis, and there was a staple that had disrupted from the anastomosis. This was reinforced in 2 layers with interrupted 3-0 Vicryl and interrupted 3-0 silk. The rectum was then instilled with air again, and there was no evidence of any further air leakage. A further attempt was made to identify both the proximal and distal bowel in hopes of obtaining adequate length to perform a diverting ileostomy but it became virtually impossible to determine proximal distal bowel and where we would be able to perform an ileostomy. Thus, the decision was made to place a drain at the anastomosis site and accept the repair that had been done so as to not cause any further damage to the bowel and any possible further enterotomies. The abdomen was then irrigated with copious amounts of normal saline, inspected for hemostasis, which was well controlled with electocautery. The bowel was inspected as best we could for any signs of any further serosal damage. Small serosal tears were repaired with interrupted 3=0 silks. A 15 French round Blake drain was then placed through a separate stab incision in the right lower quadrant and draped down into the pelvis at the site of the anastomosis. The fascial layers were then mobilized to allow closure and a running looped #1 PDS interrupted #1 Vicryls were then used to close the bdominal wall. Subcutaneous tissue was irrigated with normal saline and the skin was closed with surgical staples with NuGauze placed in between the staples.
Julie
1. Exploratory laparotomy with extensive lysis of adhesions of approx 3 hours. (separate procedure)
2. Repair and oversew of an anastomotic leak.
3. Small bowel resection and repair of enterotomy x2. (which according to another thread in this forum, should not be coded out at all) - but I'm not sure if that is true in this case because it seems to be less of physician error and more of patient's body being so fragile.
Please advise
INDICATIONS: The patient is approximately 2 weeks out from a subtotal colectomy with ileorectal anastomosis for a synchronous colon cancer. He was admitted the night before with an abdominal wound infection and subsequently began having stool from his incision.
PROCEDURE FINDINGS: Small anastomotic leak in the anterior portion of the ileorectal anastomosis. He also had significant intraabdominal adhesions and basically a frozen abdomen with extensive firbrosis.
DESCRIPTION OF PROCEDURE: A previous midline incision was opened and carried into the abdominal cavity. Upon entering the abdominal cavity, we encountered a moderate amount of free enteric contents mostly located in the left lower quadrant. This was suctioned clear and then irrigated with copious amounts of normal saline. At this point, extensive lysis of adhesions was done which was very difficult and took approximately 3 hours to clearly identify where the anastomotic leak was. During that time period, we had 2 enterotomies and multiple serosal tears and it was almost impossible to clearly identify the proximal an distal bowel. After ultimately mobilizing the proximal bowel where the enterotomy was made in the left upper quadrant, this required a side-to-side stapled anastomosis to repair the enterotomy with a small bowel resection of approximately 3 inches. This was done with a GIA-75 stapler and a TA 55 stapler. there was also another mid-jejunal enterotomy that was made with a significant deserosalization, which required a functional end-to-end side-to-side anastomosis. At this point, further dissection proved to be virtually impossible due to any type of dissection resulting in extensive serosal tears.
At this point, a rigid sigmoidoscope was placed into the rectum after frog-legging the patient, and air was instilled into the rectum and the small anastomotic leak was identified in the anterior portion of the ileorectal anastomosis, and there was a staple that had disrupted from the anastomosis. This was reinforced in 2 layers with interrupted 3-0 Vicryl and interrupted 3-0 silk. The rectum was then instilled with air again, and there was no evidence of any further air leakage. A further attempt was made to identify both the proximal and distal bowel in hopes of obtaining adequate length to perform a diverting ileostomy but it became virtually impossible to determine proximal distal bowel and where we would be able to perform an ileostomy. Thus, the decision was made to place a drain at the anastomosis site and accept the repair that had been done so as to not cause any further damage to the bowel and any possible further enterotomies. The abdomen was then irrigated with copious amounts of normal saline, inspected for hemostasis, which was well controlled with electocautery. The bowel was inspected as best we could for any signs of any further serosal damage. Small serosal tears were repaired with interrupted 3=0 silks. A 15 French round Blake drain was then placed through a separate stab incision in the right lower quadrant and draped down into the pelvis at the site of the anastomosis. The fascial layers were then mobilized to allow closure and a running looped #1 PDS interrupted #1 Vicryls were then used to close the bdominal wall. Subcutaneous tissue was irrigated with normal saline and the skin was closed with surgical staples with NuGauze placed in between the staples.
Julie