colon/rectal

tgenia

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Shakopee, Minnesota
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Hi, Our MD performed this laparscopic I don't see a code for this so I was thinking of using a unlisted code 45499 any thoughts, I tried to look for an open code to compare but I was not able to find that either.
Thanks



SURGEON
Dr Nobody,


ASSISTANT
Dr. Who,


PREOPERATIVE DIAGNOSIS
Diversion colitis.


POSTOPERATIVE DIAGNOSIS
Diversion colitis.


PROCEDURE
1. Exploratory laparoscopy.
2. Laparoscopic lysis of adhesions.
3. Laparoscopic resection of diverted rectum.
4. Rigid proctoscopy.


ESTIMATED BLOOD LOSS
20 cc.


COMPLICATIONS
None.


INDICATIONS
Ms. nobody is an 83-year-old woman who has had a sigmoid colon resection and
there was a remnant of the rectum essentially that was excluded at the time
of the anastomosis. This in itself was not unusual, but she developed colitis
and bleeding from this site. This is a little bit more unusual. She had a
multitude of bowel symptoms outlined in my consultation note. We discussed
consideration of resection of this portion of the colon. I discussed this
scenario with several physicians, and actually considered transluminal
transrectal approaches. I suggested a laparoscopic approach. We discussed at
length the potential risks, benefits, and alternatives. We discussed issues
that included but were not limited to anesthetic risk, requiring transfusion,
the risk of transfusion, infection, heart attack, stroke, death, leaks,
stenoses, reoperations, diverting colostomy, missed diagnoses, etc. We also
discussed the possibility that the procedure provide her no relief of her
symptoms. She asked very appropriate questions, as did her family. She opted
to proceed.


OPERATIVE FINDINGS
The portion of the excluded rectum was easily identifiable. There were
multiple dense adhesions that made the dissection more difficult. Once we
were able to dissect the adhesions of the pelvis, we could identify the piece
of the colon that was the problem and stapled this off and removed it. There
were no complications.


PROCEDURE
The patient was brought to the operating room, placed in a lithotomy
position, prepped and draped in the usual sterile manner. A left upper
quadrant stab incision was made, through which a Veress needle was used to
enter the abdomen. On the initial placement of the Veress needle may have
been too high. We had some concerns that maybe we punctured the diaphragm. We
removed the needle and then replaced it in a more appropriate position
(postoperative chest x-ray revealed no evidence of pneumothorax ). The
abdomen was then insufflated to 15 mmHg with CO2. The Veress needle was
removed and a 5 mm trocar and port were then introduced through the same stab
incision. Through this, a 5 mm 30 degree scope was used to inspect the
abdomen for evidence of injury from the Veress needle or the trocar itself.
None were found. Under direct laparoscopic vision, a 5 mm port was placed in
the left lower abdomen. Through these 2 ports, we were able to lyse a
significant amount of adhesions in the midline. The adhesions were the
anterior abdominal wall and included the omentum primarily. These were taken
down, primarily sharply. Some blunt dissection was also used.


In the right lower quadrant we then placed a 5 mm port and then in the
midabdomen through one of her previous scars, we placed a 12 mm port.


We inspected the pelvis. There were multiple adhesions of small bowel in the
pelvis. We very carefully dissected the small bowel free of the pelvic
adhesions. This dissection took approximately an hour and a half and was
somewhat difficult due to the relatively dense adhesions in some portions.
Ultimately, we were able to remove the small bowel from the pelvis and
examine the pelvis. There was no injury to the small bowel. We inspected very
carefully.


The anastomosis was identified. We could clearly see the anastomosis. Through
the posterior and to the patient's right was a segment of rectum that was the
source of the problem, excluded from the fecal flow. Using ultrasonic
dissection, electrocautery and blunt dissection, we were able to dissect this
posterior portion of the rectum free from its attachments, and took down the
lateral attachments. There had been lighted ureteral catheters placed
preoperatively and this facilitated our avoidance of the ureters.


Using digital exploration of the rectum, we were able to identify the
anastomosis and the excluded portion of the colon. The excluded portion of
the colon was then stapled with an echelon 45 blue stapler. This portion of
the colon was removed. Further digital examination revealed no further
evidence of excluded portion of colon. A rigid proctoscopy with insufflation
revealed that the new staple line was hemostatic. There was no air leak with
the colon being under saline.


The pelvis was then copiously irrigated. There was no evidence of bleeding.
The procedure appeared to be successful.


The removed portion of the rectum had been placed in an Endo Catch bag and
brought out through the 12 mm port site. This 12 mm port site was then closed
with a 2-0 Vicryl using a Carter-Thomason fascial closure device. The wounds
were injected with 0.25% Marcaine. The ports had been removed under direct
and laparoscopic vision. There was no evidence of bleeding. The wounds were
then closed with 4-0 Vicryl subcuticular stitches. Steri-Strips were placed.
The wounds were dressed. The patient was brought to recovery in good
condition. There were no complications and the patient tolerated the
procedure well.
 
I agree with using 45499 in this case since the excluded portion of the rectum was stapled off and removed without any re-anastamosis. In addition, I would add modifier 22 due to the 1.5 lysis of adhesions.
 
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