Hi can someone help me with this. This is my first time coding colorectal I am a new coder. Thanks I know 49000 is my exploratory, 44143 is hartmann and do I code 44139 and I am confused about the small bowel resection and drainage of chronic pelvic abcess Thanks
PREOPERATIVE DIAGNOSES:
1.Diverticulitis , left colon with probable small bowel and bladder fistula.
2. Chronic bowel obstruction .
POSTOPERATIVE DIAGNOSES:
Massive diverticular disease, left colon.
Small bowel fistula.
colovesical fistula.
Chronic abscess with phlegmon.
SURGICAL PROCEDURE (S) PERFORMED:
1 . Exploratory laparotomy.
2. Left hemi colectomy with sigmoid Hartmann and transverse colostomy.
3. Mobilization Of splenic flexure.
4. Small bowel resection with primary anastomosis .
5 . Drainage of chronic pelvic abscess with repair of bladder fistula after resection.
TYPE OF ANESTHESIA ADMINISTERED:
General endotracheaL tuba1 and TAP block.
SPECIMEN (S) REMOVED:
Left colon and small bowel .
ESTIMATED BLOOD LOSS:
300mL.
COMPLICAT IONS : None .
DRAINS :
Two; left—sided and pelvic Blake drains .
COUNTS :
Correct .
BRIEF CLINICAL HISTORY:
The patient is a male with a history of diverticulitis. He has undergone workup including colonoscopy, CT scans . He was scheduled for elective surgery, but is very noncompliant, did not come in. The risks and benefits of the operation were fully explained to the patient including risk of bleeding, infection, reoperation, colostomy, heart: attack, pneumonia, stroke, and blood clot formations . He has been seen by stomal therapy preoperatively . He has g t chronic renal insufficiency, chronic pain patient, and massive we ight loss . We now present for surgery.
DESCRIPTION OF PROCEDURE:
The patient was taken to OR room #22, laid supine on the table, given general anesthesia by Dr. Belitsos without difficulties. The pneumatic compression stockings were placed. His legs were placed in Allen stirrups . Foley catheter was placed under sterile technique . His abdomen was prepped and draped in usual sterile fashion . A midline skin incision was made using skin knife, taken sharply through subcutaneous tissues . Upon entering the abdominal cavity, it was noted he had very attenuated fascia, muscle layers, and abdominal wall secondary to most likely the weight loss. After entering his abdominal cavity we systematically explored it. Liver was normal. Small bowel was normal . There was a loop of small bowel stuck to the sigmoid colon consistent with the findings on the CT scan consistent with a small bowel fistula He also had a colovesical fistula in the vicinity with a chronic abscess. His entire left colon from the splenic flexure to the upper sigmoid colon was a massive phlegmon embedded in the retroperitoneum and left abdominal side wall, stuck like concrete, obviously a chronic severe phlegmon. The tissue planes were obliterated . There was no peritoneal reflection to score. We simply went through the fibrotic phlegmon tissue. After laborious dissection, we were finally able to mobilize the descending sigmoid colon, again massive phlegmon. There was contamination with perforation . Chronic perforation contained on t descending sigmoid colon. Eventually, we were able to free up the entire left hemicolon. After careful dissection, we were able to identify the eft ureter, swept it inferiorly after dissection for about an hour. A point was chosen i the mid sigmoid colon, divided the bowels using a cutter 7 5 stapler. The splenic flexure was taken under direct vision using electrocautery device. The greater omentum was taken Off the transverse colon using electrocautery devic . The left colon was then resected using the LigaSure with double burn technique on name vessels . Finally, we were able to resect the left colon; we opened it up There was no obvious neoplastic disease, just a massive chronic phlegmon with diverticular disease . Because of the contamination, we then copiously irrigated with about 5 or 6L of warm normal saline, cleaning the area. Upon dissection, it was noted there was a small bowel fistula with the defect in the small bowel; this was resected. A point was chosen around the small bowel to divide the bowels using a cutter 75 staplers on either side. The mesentery was taken down using the LigaSure . Antimesenteric borders of staple line were grasped using Allis clamps, clipped off using curved Mayo scissors . Each 1 imb of the 75 stapler was placed in the lumen of bowel, fired in a side—to—side fashion . The enterotomy sites were grasped using Allis clamps and closed using a TA—60 staple line. The entire anastomotic line was oversewn using 3—0 Vicry Lembert suture . There was no tension and good blood supply. After this was then done, we then meticulously examined the left gutter. The left kidney had the Gerota's fascia that had been exposed off with the phlegmon. No injuries were noted. We did not identify the pancreas, but the left ureter was identified and swept inferiorly. At that point, the chronic abscess cavity, which was eroded from the fistula to the dome of the bladder was debrided . We then closed the peritoneum over the bladder fistula using a 3—0 chromic interrupted simple suture. We then placed 2 Blake drains in the left abdomen, draining the left gutter and going down to the pelvis. These were sutured int place using C silk sutures. A colostomy site was created to the left upper quadrant site after a button of skin was removed using electrocautery device . It was dilated up to 2 fingerbreadths through the abdominal wall through a cruciate incision . The distal transverse colon was brought through the colostomy site without any tension and no twisting. At that point, all laps were removed . Lap count, sponge count, and instrument count were all correct x2. We placed 2 sheets of AmnioPix over the bladder f {stula repair. We place 2 sheets Of AmnioFix over the small bowel resection, dropped them back into t abdominal cavity. What was Left over the omentum was placed over the small bowel . Closure was then begun. The abdominal wall muscle layers were closed using double—stranded PDS running simple suture, several intermittent retention sutures of #1 Vicryl placed and tied down snugly. As I mentioned, the abdomi1 wall was extremely tenuous . The subcutaneous tissue was irrigated with warm normal saline. Muscle and fascia 1 layers were infiltrated using 4 OmL of Exparel . The skin was approximated and closed using the skin stapler. Attention was then turned to the colostomy. The tip of the colostomy was excised using electrocautery device . There were good arterial bleeding edges . It was matured using a 3—0 chromic interrupted simple suture in a Brooke fashion . There was no tension on the colostomy. Mucosa was pink and viable. The drains were hooked to close suction. Sterile gauze dressings were applied Colostomy bag was applied. The patient remained intubated, was taken to the recovery room in guarded condition. It was noted he had hypotension during t e case. He was transfused 2 units of blood intraoperatively because we started off with anemia and he was kept on low—dose Levophed.
PREOPERATIVE DIAGNOSES:
1.Diverticulitis , left colon with probable small bowel and bladder fistula.
2. Chronic bowel obstruction .
POSTOPERATIVE DIAGNOSES:
Massive diverticular disease, left colon.
Small bowel fistula.
colovesical fistula.
Chronic abscess with phlegmon.
SURGICAL PROCEDURE (S) PERFORMED:
1 . Exploratory laparotomy.
2. Left hemi colectomy with sigmoid Hartmann and transverse colostomy.
3. Mobilization Of splenic flexure.
4. Small bowel resection with primary anastomosis .
5 . Drainage of chronic pelvic abscess with repair of bladder fistula after resection.
TYPE OF ANESTHESIA ADMINISTERED:
General endotracheaL tuba1 and TAP block.
SPECIMEN (S) REMOVED:
Left colon and small bowel .
ESTIMATED BLOOD LOSS:
300mL.
COMPLICAT IONS : None .
DRAINS :
Two; left—sided and pelvic Blake drains .
COUNTS :
Correct .
BRIEF CLINICAL HISTORY:
The patient is a male with a history of diverticulitis. He has undergone workup including colonoscopy, CT scans . He was scheduled for elective surgery, but is very noncompliant, did not come in. The risks and benefits of the operation were fully explained to the patient including risk of bleeding, infection, reoperation, colostomy, heart: attack, pneumonia, stroke, and blood clot formations . He has been seen by stomal therapy preoperatively . He has g t chronic renal insufficiency, chronic pain patient, and massive we ight loss . We now present for surgery.
DESCRIPTION OF PROCEDURE:
The patient was taken to OR room #22, laid supine on the table, given general anesthesia by Dr. Belitsos without difficulties. The pneumatic compression stockings were placed. His legs were placed in Allen stirrups . Foley catheter was placed under sterile technique . His abdomen was prepped and draped in usual sterile fashion . A midline skin incision was made using skin knife, taken sharply through subcutaneous tissues . Upon entering the abdominal cavity, it was noted he had very attenuated fascia, muscle layers, and abdominal wall secondary to most likely the weight loss. After entering his abdominal cavity we systematically explored it. Liver was normal. Small bowel was normal . There was a loop of small bowel stuck to the sigmoid colon consistent with the findings on the CT scan consistent with a small bowel fistula He also had a colovesical fistula in the vicinity with a chronic abscess. His entire left colon from the splenic flexure to the upper sigmoid colon was a massive phlegmon embedded in the retroperitoneum and left abdominal side wall, stuck like concrete, obviously a chronic severe phlegmon. The tissue planes were obliterated . There was no peritoneal reflection to score. We simply went through the fibrotic phlegmon tissue. After laborious dissection, we were finally able to mobilize the descending sigmoid colon, again massive phlegmon. There was contamination with perforation . Chronic perforation contained on t descending sigmoid colon. Eventually, we were able to free up the entire left hemicolon. After careful dissection, we were able to identify the eft ureter, swept it inferiorly after dissection for about an hour. A point was chosen i the mid sigmoid colon, divided the bowels using a cutter 7 5 stapler. The splenic flexure was taken under direct vision using electrocautery device. The greater omentum was taken Off the transverse colon using electrocautery devic . The left colon was then resected using the LigaSure with double burn technique on name vessels . Finally, we were able to resect the left colon; we opened it up There was no obvious neoplastic disease, just a massive chronic phlegmon with diverticular disease . Because of the contamination, we then copiously irrigated with about 5 or 6L of warm normal saline, cleaning the area. Upon dissection, it was noted there was a small bowel fistula with the defect in the small bowel; this was resected. A point was chosen around the small bowel to divide the bowels using a cutter 75 staplers on either side. The mesentery was taken down using the LigaSure . Antimesenteric borders of staple line were grasped using Allis clamps, clipped off using curved Mayo scissors . Each 1 imb of the 75 stapler was placed in the lumen of bowel, fired in a side—to—side fashion . The enterotomy sites were grasped using Allis clamps and closed using a TA—60 staple line. The entire anastomotic line was oversewn using 3—0 Vicry Lembert suture . There was no tension and good blood supply. After this was then done, we then meticulously examined the left gutter. The left kidney had the Gerota's fascia that had been exposed off with the phlegmon. No injuries were noted. We did not identify the pancreas, but the left ureter was identified and swept inferiorly. At that point, the chronic abscess cavity, which was eroded from the fistula to the dome of the bladder was debrided . We then closed the peritoneum over the bladder fistula using a 3—0 chromic interrupted simple suture. We then placed 2 Blake drains in the left abdomen, draining the left gutter and going down to the pelvis. These were sutured int place using C silk sutures. A colostomy site was created to the left upper quadrant site after a button of skin was removed using electrocautery device . It was dilated up to 2 fingerbreadths through the abdominal wall through a cruciate incision . The distal transverse colon was brought through the colostomy site without any tension and no twisting. At that point, all laps were removed . Lap count, sponge count, and instrument count were all correct x2. We placed 2 sheets of AmnioPix over the bladder f {stula repair. We place 2 sheets Of AmnioFix over the small bowel resection, dropped them back into t abdominal cavity. What was Left over the omentum was placed over the small bowel . Closure was then begun. The abdominal wall muscle layers were closed using double—stranded PDS running simple suture, several intermittent retention sutures of #1 Vicryl placed and tied down snugly. As I mentioned, the abdomi1 wall was extremely tenuous . The subcutaneous tissue was irrigated with warm normal saline. Muscle and fascia 1 layers were infiltrated using 4 OmL of Exparel . The skin was approximated and closed using the skin stapler. Attention was then turned to the colostomy. The tip of the colostomy was excised using electrocautery device . There were good arterial bleeding edges . It was matured using a 3—0 chromic interrupted simple suture in a Brooke fashion . There was no tension on the colostomy. Mucosa was pink and viable. The drains were hooked to close suction. Sterile gauze dressings were applied Colostomy bag was applied. The patient remained intubated, was taken to the recovery room in guarded condition. It was noted he had hypotension during t e case. He was transfused 2 units of blood intraoperatively because we started off with anemia and he was kept on low—dose Levophed.
