herrera4
Guru
i need help breaking down this note
PROCEDURE: The patient was brought to the operating room and placed in a supine position. Following induction of general anesthesia, wide ureteral stents were placed by Dr. and this will be dictated in a separate note. With the patient in the modified Llyod-Davies stirrups and all bony prominences padded, the patient was prepped and draped in the usual sterile fashion using ChloraPrep. After an appropriate timeout a small vertical incision was made at the inferior aspect of the umbilicus. This was carried down through skin and subcutaneous tissue. The fascia was incised in a vertical orientation. The edges were elevated and the peritoneal cavity was entered under direct visualization with a hemostat followed by placement of a 12 mm port. Pneumoperitoneum was established. Under direct visualization additional ports were placed in the right lower quadrant. This was a 12 mm AirSeal port. A 5 mm port was placed in the left mid abdomen, a 5 mm port was placed in the left upper quadrant, and a 12 mm port was placed in the left lower quadrant. The patient was placed in Trendelenburg position. Inflammatory adhesions to the abdominal wall were taken down. The uterus was reflected anteriorly using a peanut dissector through the left upper quadrant incision. The lateral peritoneal attachments were taken down, and the was reflected peritoneum over the pouch of Douglas to localize the tumor. The tattoo was just below the peritoneal reflection. Accordingly anterior resection was carried out first onto the rectal wall. Lateral dissection was carried out taking care to obtain the appropriate presacral plane to excise the entire mesorectal nodal packet. The dissection was greatly facilitated by the presence of the lighted ureteral stents. Once a point of transection was chosen distally, the lateral peritoneal dissection was carried up over the splenic flexure which was mobilized completely over the level of the mid transverse colon. This included reflection of the colon from the omentum. Once we were satisfied that we had adequate length, a clamp was placed at the point of transection and the operating surgeon performed sigmoidoscopy. The clamp was removed and the tumor was noted to be at 15 cm. A clip was placed at the point of transection at around 10 cm. The operating surgeon then rescrubbed and the rectum was divided using multiple firings of endo-GIA with the purple followed by blue loads.
At this point the left upper quadrant incision was extended medially. The left rectus sheath was incised and the rectus muscle was retracted medially. The peritoneum was then opened and the medial wound protector was placed. The bowel was exteriorized through this incision and the proposed point of transection in the descending colon was noted. Mesenteric attachments were divided. The bowel was then divided between Allen clamps and passed off the table. A purse-string suture of 2-0 Prolene was placed sizing the colon to 28 mm. There was some spasm noted of the colon. However, the anvil fit nicely without tension. The purse-string was tied down. Bowel was returned to the abdominal cavity and the operating surgeon changed gloves. Pneumoperitoneum was re-established by twisting the wound protector 720 degrees and occluding this with an Allen clamp. The operating surgeon then performed sigmoidoscopy of the rectal stump. With Ancef solution in the pelvis there was no evidence of air leak bubbles. The stapler was then advanced after advancing the 28 mm sizer. The spike was extruded just posterior to the staple line. The proximal colon containing the anvil was then docked. Orientation was checked. The device was closed and fired until two complete anastomotic rings were recovered. The operating surgeon again rescrubbed and three sutures of 2-0 silk were placed to "inkwell" the anastomosis to the rectum and anterior peritoneum for further reinforcement. 10 mL of Tisseel was then sprayed on the anastomosis. Final irrigation was carried out. .........
i have 44207, 44213 but not sure ...thanks for any help
PROCEDURE: The patient was brought to the operating room and placed in a supine position. Following induction of general anesthesia, wide ureteral stents were placed by Dr. and this will be dictated in a separate note. With the patient in the modified Llyod-Davies stirrups and all bony prominences padded, the patient was prepped and draped in the usual sterile fashion using ChloraPrep. After an appropriate timeout a small vertical incision was made at the inferior aspect of the umbilicus. This was carried down through skin and subcutaneous tissue. The fascia was incised in a vertical orientation. The edges were elevated and the peritoneal cavity was entered under direct visualization with a hemostat followed by placement of a 12 mm port. Pneumoperitoneum was established. Under direct visualization additional ports were placed in the right lower quadrant. This was a 12 mm AirSeal port. A 5 mm port was placed in the left mid abdomen, a 5 mm port was placed in the left upper quadrant, and a 12 mm port was placed in the left lower quadrant. The patient was placed in Trendelenburg position. Inflammatory adhesions to the abdominal wall were taken down. The uterus was reflected anteriorly using a peanut dissector through the left upper quadrant incision. The lateral peritoneal attachments were taken down, and the was reflected peritoneum over the pouch of Douglas to localize the tumor. The tattoo was just below the peritoneal reflection. Accordingly anterior resection was carried out first onto the rectal wall. Lateral dissection was carried out taking care to obtain the appropriate presacral plane to excise the entire mesorectal nodal packet. The dissection was greatly facilitated by the presence of the lighted ureteral stents. Once a point of transection was chosen distally, the lateral peritoneal dissection was carried up over the splenic flexure which was mobilized completely over the level of the mid transverse colon. This included reflection of the colon from the omentum. Once we were satisfied that we had adequate length, a clamp was placed at the point of transection and the operating surgeon performed sigmoidoscopy. The clamp was removed and the tumor was noted to be at 15 cm. A clip was placed at the point of transection at around 10 cm. The operating surgeon then rescrubbed and the rectum was divided using multiple firings of endo-GIA with the purple followed by blue loads.
At this point the left upper quadrant incision was extended medially. The left rectus sheath was incised and the rectus muscle was retracted medially. The peritoneum was then opened and the medial wound protector was placed. The bowel was exteriorized through this incision and the proposed point of transection in the descending colon was noted. Mesenteric attachments were divided. The bowel was then divided between Allen clamps and passed off the table. A purse-string suture of 2-0 Prolene was placed sizing the colon to 28 mm. There was some spasm noted of the colon. However, the anvil fit nicely without tension. The purse-string was tied down. Bowel was returned to the abdominal cavity and the operating surgeon changed gloves. Pneumoperitoneum was re-established by twisting the wound protector 720 degrees and occluding this with an Allen clamp. The operating surgeon then performed sigmoidoscopy of the rectal stump. With Ancef solution in the pelvis there was no evidence of air leak bubbles. The stapler was then advanced after advancing the 28 mm sizer. The spike was extruded just posterior to the staple line. The proximal colon containing the anvil was then docked. Orientation was checked. The device was closed and fired until two complete anastomotic rings were recovered. The operating surgeon again rescrubbed and three sutures of 2-0 silk were placed to "inkwell" the anastomosis to the rectum and anterior peritoneum for further reinforcement. 10 mL of Tisseel was then sprayed on the anastomosis. Final irrigation was carried out. .........
i have 44207, 44213 but not sure ...thanks for any help