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Rectosigmoid Resection enbloc with hysterectomy -- help needed
I have a coding scenario where the surgeon did rectosigmoid colon resection enbloc with Radical hysterectomy plus BSO etc ...
Anybody out there has any idea on how to code this case.
I came up with the codes as:
58954
44140-51
44139
Any suggestions or pointers are greatly appreciated.
here is the op report:
POSTOPERATIVE DIAGNOSES
1. Pelvic mass.
2. At least stage II ovarian adenocarcinoma based on frozen section.
PROCEDURE
1. Diagnostic laparoscopy.
2. Exploratory laparotomy.
3. Modified radical hysterectomy plus bilateral salpingo-oophorectomy
with en bloc low anterior rectal resection with reanastomosis.
4. Indicated appendectomy.
5. Gastrocolic omentectomy.
6. Splenic flexure colonic mobilization.
7. Bilateral pelvic and periaortic lymphadenectomy.
SPECIMENS
1. Pelvic washings.
2. Uterus, cervix, bilateral fallopian tubes and ovaries and
rectosigmoid.
3. Appendix.
4. Gastrocolic omentum.
5. Right and left pelvic and right and left periaortic lymph nodes.
6. Anastomotic donuts x2.
OPERATIVE TECHNIQUE
The patient was taken to the operating room where general endotracheal
anesthesia was induced without complications. The patient received
antibiotic prophylaxis per hospital protocol. Sequential compression
devices were applied to the lower extremities and activated prior to
induction of anesthesia. The patient was placed in the dorsal
lithotomy position on Allen stirrups and her abdomen, perineum and
vagina were prepped and draped in the usual sterile fashion.
Diagnostic laparoscopy was first performed. A 5-mm incision was made
underneath the left costal mass margin after local infiltration of
0.25% bupivacaine. Using the Endopath Excel trocar, the abdominal
cavity was entered under direct visualization. Pneumoperitoneum was
created to a maximal pressure of 15 mmHg. The above-mentioned
findings were noted. There was no evidence of carcinomatosis.
Therefore, the decision was made to proceed with laparotomy.
A midline infra and supraumbilical laparotomy was made, using electrocautery.
The abdominal cavity was entered sharply without difficulties. The
incision was extended superiorly and inferiorly with good
visualization of the intra-abdominal contents. The above-mentioned
findings were again confirmed. At this point, the Bookwalter retractor
was assembled with careful attention taken to prevent compression of
neurovascular structures with the retractor blades. Moist operative
sponges were used to pack a small bowels out of the way, in order to
maximize exposure. The right and left round ligaments were divided
with electrocautery. The vesicouterine peritoneal reflection was
divided using electrocautery and the bladder was mobilized anteriorly.
The right and left paravesical and pararectal spaces were developed
and the ureters were clearly identified. On the right side, the
ovarian vessels were skeletonized, doubly clamped, divided and doubly
suture ligated using 0 Vicryl. On the left side, the incision was
extended superiorly along the avascular line of Toldt in order to
further mobilized the left retroperitoneum. The ureter was mobilized
in order to allow upward mobilization of the proximal sigmoid colon.
The bowel wall was isolated and divided using a 75 GIA stapler. The
mesentery was skeletonized and the inferior mesenteric artery was
isolated, clamped, divided and doubly suture ligated using 0 Vicryl.
The ureters were kept under direct visualization and away from all
areas of dissection at all times. At this point, the presacral space
was developed in order to perform total mesorectal excision en bloc
with the rectosigmoid, uterus and ovaries. The left ureter was
completely mobilized to the level of the ureteral tunnel. The left
uterine artery was identified at the origin, doubly clipped, divided
sharply with scissors and the left parametrium was elevated above the
ureter nor to mobilize the ureter away from the surgical specimen. On
the right side, it was possible to divide the uterine vessels high
above the ureters and this pedicle was divided and suture ligated
using 0 Vicryl. At this point, a sponge stick was placed in the
vagina. Anterior colpotomy was made. Lateral vaginal pillars and
rectal pillars were serially clamped, divided and suture ligated using
0 Vicryl. The posterior vagina was then entered and the rectovaginal
septum was developed. Dissection was taken within the rectovaginal
septum below the level of the peritoneal reflection. The peripheral
attachment from the rectosigmoid were easily mobilized, again
maintaining the mesorectum intact. At this point, posteriorly, the
mesorectum was isolated, clamped, divided and suture ligated using 0
Vicryl. Using a contour stapler with a green load, the rectum was
divided below the level of all gross visible tumor and the specimen
was sent for frozen. Report was consistent with adenocarcinoma of
ovarian primary, favoring endometrioid type. In the absence of
obviously metastatic disease, outside the pelvis, the decision was
made to proceed with a pelvic and para-aortic indicated
lymphadenectomy for staging. All lymph node-bearing tissue between the
level of the mid common iliac vessels proximally, the deep circumflex
iliac veins distally, the superior vesical artery medially and the
obturator nerve inferiorly was excised using a combination of sharp
and blunt dissection on both sides. The specimens were labeled right
and left pelvic lymph nodes. In the periaortic regions, all lymph
node-bearing tissue located between the mid common iliac and the renal
vessels was excised on both sides using a combination of sharp and
blunt dissection. The ureters were retracted and kept out of harm's
way at all times. These specimens were labeled right and left
periaortic lymph nodes. At this point, a gastrocolic omentectomy was
performed. The lesser sac was entered. Attachments from the omentum to
the greater curvature of the stomach and the transverse colon were
serially divided using electrocautery and the Enseal instrument. The
specimen was labeled gastrocolic omentum. An indicated appendectomy
was performed as the appendix appeared quite obliterated. The base of
the appendix was isolated and transected using a GIA stapler. The
mesoappendix was serially divided using the Enseal device.
Attention was then turned to the mobilization of the left colon in order to
facilitate an anastomosis without tension. The avascular line of Toldt
was further mobilized in a cephalad direction. All attachments from
the splenic flexure to the surrounding peritoneal structures were
divided using electrocautery. This allowed mobilization of the colon.
However, in order to reach the pelvis without tension, it was
necessary to isolate, clamp, divided and suture ligated the inferior
mesenteric vein. This allowed to a full mobilization of the left colon
without any tension. At this point, the staple line was caught and the
anvil of a 29 EEA stapler was secured to the proximal colonic segment
using the pursestring device with 2-0 Prolene. During the excision of
the staple line, brisk capillary bleeding was noted, confirming good
perfusion of the proximal bowel segment. At this point, the long end
of the end-to-end anastomotic stapler was advanced through the rectum.
The colorectal anastomosis was created without any tension.
The anastomosis was tested by submerging it in water and inflating the
rectum with a rigid proctoscope. There was no evidence of bubble
leaks. At this point, all areas of dissection were inspected.
Excellent hemostasis was confirmed.
Thank you
I have a coding scenario where the surgeon did rectosigmoid colon resection enbloc with Radical hysterectomy plus BSO etc ... Anybody out there has any idea on how to code this case.
I came up with the codes as:
58954
44140-51
44139
Any suggestions or pointers are greatly appreciated.
here is the op report:
POSTOPERATIVE DIAGNOSES
1. Pelvic mass.
2. At least stage II ovarian adenocarcinoma based on frozen section.
PROCEDURE
1. Diagnostic laparoscopy.
2. Exploratory laparotomy.
3. Modified radical hysterectomy plus bilateral salpingo-oophorectomy
with en bloc low anterior rectal resection with reanastomosis.
4. Indicated appendectomy.
5. Gastrocolic omentectomy.
6. Splenic flexure colonic mobilization.
7. Bilateral pelvic and periaortic lymphadenectomy.
SPECIMENS
1. Pelvic washings.
2. Uterus, cervix, bilateral fallopian tubes and ovaries and
rectosigmoid.
3. Appendix.
4. Gastrocolic omentum.
5. Right and left pelvic and right and left periaortic lymph nodes.
6. Anastomotic donuts x2.
OPERATIVE TECHNIQUE
The patient was taken to the operating room where general endotracheal
anesthesia was induced without complications. The patient received
antibiotic prophylaxis per hospital protocol. Sequential compression
devices were applied to the lower extremities and activated prior to
induction of anesthesia. The patient was placed in the dorsal
lithotomy position on Allen stirrups and her abdomen, perineum and
vagina were prepped and draped in the usual sterile fashion.
Diagnostic laparoscopy was first performed. A 5-mm incision was made
underneath the left costal mass margin after local infiltration of
0.25% bupivacaine. Using the Endopath Excel trocar, the abdominal
cavity was entered under direct visualization. Pneumoperitoneum was
created to a maximal pressure of 15 mmHg. The above-mentioned
findings were noted. There was no evidence of carcinomatosis.
Therefore, the decision was made to proceed with laparotomy.
A midline infra and supraumbilical laparotomy was made, using electrocautery.
The abdominal cavity was entered sharply without difficulties. The
incision was extended superiorly and inferiorly with good
visualization of the intra-abdominal contents. The above-mentioned
findings were again confirmed. At this point, the Bookwalter retractor
was assembled with careful attention taken to prevent compression of
neurovascular structures with the retractor blades. Moist operative
sponges were used to pack a small bowels out of the way, in order to
maximize exposure. The right and left round ligaments were divided
with electrocautery. The vesicouterine peritoneal reflection was
divided using electrocautery and the bladder was mobilized anteriorly.
The right and left paravesical and pararectal spaces were developed
and the ureters were clearly identified. On the right side, the
ovarian vessels were skeletonized, doubly clamped, divided and doubly
suture ligated using 0 Vicryl. On the left side, the incision was
extended superiorly along the avascular line of Toldt in order to
further mobilized the left retroperitoneum. The ureter was mobilized
in order to allow upward mobilization of the proximal sigmoid colon.
The bowel wall was isolated and divided using a 75 GIA stapler. The
mesentery was skeletonized and the inferior mesenteric artery was
isolated, clamped, divided and doubly suture ligated using 0 Vicryl.
The ureters were kept under direct visualization and away from all
areas of dissection at all times. At this point, the presacral space
was developed in order to perform total mesorectal excision en bloc
with the rectosigmoid, uterus and ovaries. The left ureter was
completely mobilized to the level of the ureteral tunnel. The left
uterine artery was identified at the origin, doubly clipped, divided
sharply with scissors and the left parametrium was elevated above the
ureter nor to mobilize the ureter away from the surgical specimen. On
the right side, it was possible to divide the uterine vessels high
above the ureters and this pedicle was divided and suture ligated
using 0 Vicryl. At this point, a sponge stick was placed in the
vagina. Anterior colpotomy was made. Lateral vaginal pillars and
rectal pillars were serially clamped, divided and suture ligated using
0 Vicryl. The posterior vagina was then entered and the rectovaginal
septum was developed. Dissection was taken within the rectovaginal
septum below the level of the peritoneal reflection. The peripheral
attachment from the rectosigmoid were easily mobilized, again
maintaining the mesorectum intact. At this point, posteriorly, the
mesorectum was isolated, clamped, divided and suture ligated using 0
Vicryl. Using a contour stapler with a green load, the rectum was
divided below the level of all gross visible tumor and the specimen
was sent for frozen. Report was consistent with adenocarcinoma of
ovarian primary, favoring endometrioid type. In the absence of
obviously metastatic disease, outside the pelvis, the decision was
made to proceed with a pelvic and para-aortic indicated
lymphadenectomy for staging. All lymph node-bearing tissue between the
level of the mid common iliac vessels proximally, the deep circumflex
iliac veins distally, the superior vesical artery medially and the
obturator nerve inferiorly was excised using a combination of sharp
and blunt dissection on both sides. The specimens were labeled right
and left pelvic lymph nodes. In the periaortic regions, all lymph
node-bearing tissue located between the mid common iliac and the renal
vessels was excised on both sides using a combination of sharp and
blunt dissection. The ureters were retracted and kept out of harm's
way at all times. These specimens were labeled right and left
periaortic lymph nodes. At this point, a gastrocolic omentectomy was
performed. The lesser sac was entered. Attachments from the omentum to
the greater curvature of the stomach and the transverse colon were
serially divided using electrocautery and the Enseal instrument. The
specimen was labeled gastrocolic omentum. An indicated appendectomy
was performed as the appendix appeared quite obliterated. The base of
the appendix was isolated and transected using a GIA stapler. The
mesoappendix was serially divided using the Enseal device.
Attention was then turned to the mobilization of the left colon in order to
facilitate an anastomosis without tension. The avascular line of Toldt
was further mobilized in a cephalad direction. All attachments from
the splenic flexure to the surrounding peritoneal structures were
divided using electrocautery. This allowed mobilization of the colon.
However, in order to reach the pelvis without tension, it was
necessary to isolate, clamp, divided and suture ligated the inferior
mesenteric vein. This allowed to a full mobilization of the left colon
without any tension. At this point, the staple line was caught and the
anvil of a 29 EEA stapler was secured to the proximal colonic segment
using the pursestring device with 2-0 Prolene. During the excision of
the staple line, brisk capillary bleeding was noted, confirming good
perfusion of the proximal bowel segment. At this point, the long end
of the end-to-end anastomotic stapler was advanced through the rectum.
The colorectal anastomosis was created without any tension.
The anastomosis was tested by submerging it in water and inflating the
rectum with a rigid proctoscope. There was no evidence of bubble
leaks. At this point, all areas of dissection were inspected.
Excellent hemostasis was confirmed.
Thank you
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