Would someone help with the CPT's for this procedure? Much appreciated!
POSTOPERATIVE DIAGNOSES:
1. Small bowel obstruction.
2. Perforated small bowel tumor.
PROCEDURES:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Resection and primary anastomosis of small bowel.
The incision from her previous operation was then incised. The abdomen was then entered. There was murky purulent fluid noted in the abdomen, but no puss. The small bowel appeared to be dilated but noted viable. The patient was eviscerated and the small bowel was run, beginning at the ligament of Treitz. At what appeared to be the distal jejunum proximal ileum, found significant amount of inflammation. The bowel appeared to be adhered together. These adhesions were sharply lysed. In addition there appeared to be inflammatory rind similar to that found in phlegmons or early abscess cavities. This rind was peeled off and it was at this point that a focal nodule was noted in the wall of small bowel, and the nodule appeared to be approximately 1-1.5 cm in diameter. Judging from the local inflammatory reaction, it is presumed that there was a perforation or microperforation at this site leading to a local inflammatory response. Tracing the bowel further distal, the inflamed bowel had folded on to itself and twisting from the antimesenteric side to the mesentery, and was scarred down. This appears to be the transition point of the obstruction and the likely source of her problems. Once this was relieved the bowel appeared to dilate well. Given this mass, the decision was made to make a bowel resection and remove the source of the perforation. The points of transection were identified and divided with Endo-GIA stapler. The mesentery was divided. Standard stapled anastomosis was then performed, The mesenteric defect was then closed. The bowel was then traced down to the ileocecal junction. The inflammatory mass was then delivered from the pelvis and the cecum had been mildly associated. The appendix was then identified and noted to be normal with no evidence of perforation. It was left in situ. The cecum appeared to be lightly adhered to the vaginal cuff from her hysterectomy, but there does not appear to be any evidence of fistulization or division. The colon was then thoroughly examined and there were no lesions noted. Examination of the liver noted small nodules on the most posterior aspect of the liver, but given the position, visualization was difficult. These nodules by palpation appeared to be less than 0.5 cm in diameter. The stomach, spleen and remainder of the colon were examined. The colonic anastomosis appeared to be nodular but visual inspection was unable to note any evidence of perforation or breakdown of the anastomosis. Recurrence at the site was not identified. The abdomen was then copiously irrigated. The bowel was returned to the abdomen. The fascia was then closed with a running looped PDS. The skin was then loosely closed with staples. Dressings were then applied.
POSTOPERATIVE DIAGNOSES:
1. Small bowel obstruction.
2. Perforated small bowel tumor.
PROCEDURES:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Resection and primary anastomosis of small bowel.
The incision from her previous operation was then incised. The abdomen was then entered. There was murky purulent fluid noted in the abdomen, but no puss. The small bowel appeared to be dilated but noted viable. The patient was eviscerated and the small bowel was run, beginning at the ligament of Treitz. At what appeared to be the distal jejunum proximal ileum, found significant amount of inflammation. The bowel appeared to be adhered together. These adhesions were sharply lysed. In addition there appeared to be inflammatory rind similar to that found in phlegmons or early abscess cavities. This rind was peeled off and it was at this point that a focal nodule was noted in the wall of small bowel, and the nodule appeared to be approximately 1-1.5 cm in diameter. Judging from the local inflammatory reaction, it is presumed that there was a perforation or microperforation at this site leading to a local inflammatory response. Tracing the bowel further distal, the inflamed bowel had folded on to itself and twisting from the antimesenteric side to the mesentery, and was scarred down. This appears to be the transition point of the obstruction and the likely source of her problems. Once this was relieved the bowel appeared to dilate well. Given this mass, the decision was made to make a bowel resection and remove the source of the perforation. The points of transection were identified and divided with Endo-GIA stapler. The mesentery was divided. Standard stapled anastomosis was then performed, The mesenteric defect was then closed. The bowel was then traced down to the ileocecal junction. The inflammatory mass was then delivered from the pelvis and the cecum had been mildly associated. The appendix was then identified and noted to be normal with no evidence of perforation. It was left in situ. The cecum appeared to be lightly adhered to the vaginal cuff from her hysterectomy, but there does not appear to be any evidence of fistulization or division. The colon was then thoroughly examined and there were no lesions noted. Examination of the liver noted small nodules on the most posterior aspect of the liver, but given the position, visualization was difficult. These nodules by palpation appeared to be less than 0.5 cm in diameter. The stomach, spleen and remainder of the colon were examined. The colonic anastomosis appeared to be nodular but visual inspection was unable to note any evidence of perforation or breakdown of the anastomosis. Recurrence at the site was not identified. The abdomen was then copiously irrigated. The bowel was returned to the abdomen. The fascia was then closed with a running looped PDS. The skin was then loosely closed with staples. Dressings were then applied.