jdibble
True Blue
Any suggestions on the correct codes for this surgery:
MATERIAL FORWARDED TO LAB: Portion of ileum.
FINDINGS: The patient was noted to have moderately dilated small bowel to the mid ileum. A loop of mid ileum was densely adhesed into the low pelvis alongside his previous low coloproctostomy anastomosis. There was a small abscess in the pelvis covered over by the small bowel. The patient was also noted to have a fingertip sized opening in the posterior aspect of his anastomosis at the staple line, deep in his pelvis just above the dentate line in the rectum. This is presumed to be present from the original surgery on 02/11/2013. It was felt to be the source of the original purulent drainage. It was felt likely to be patched over by the loop of distal ileum which was densely adhered into the pelvis and was effectively patched; however, it caused the high-grade partial bowel obstruction. Throughout the remainder of the abdomen there were minimal adhesions but diffusely dilated small bowel. The colon itself was not dilated but appeared grossly normal, other than at the anastomosis posteriorly. It was difficult but not impossible to approach the posterior aspect of the low pelvic anastomosis from the abdominal side. It was approachable through the rectum and was repaired through the rectum for that reason. Diverting colostomy was performed to divert the stream away from the repaired anastomosis in hopes of it healing without further leakage.
PROCEDURE: The patient was taken to the main operating room, given general anesthesia, and prepped and draped in a sterile fashion. Initial entry into the abdomen was made through a 5 mm incision in the left upper quadrant at the costal margin. A Veress needle was inserted, and the abdomen was insufflated with CO2. A 5 port was then placed bluntly into through that incision using the Optiview to technique. The abdominal cavity was entered. Laparoscope was placed down through this port. The omentum was noted to be densely adherent to the anterior abdominal wall. It was bluntly taken down with the laparoscope revealing access to the anterior abdominal wall on the patient's left side. Another 5 port was placed in the left hypogastrium and a third 5 port was placed in the left lower quadrant bluntly penetrating through the abdominal wall under direct vision. With these ports in place and with blunt dissection, the omentum was taken down off the abdominal wall, allowing exposure to the abdominal cavity. Visualization revealed markedly dilated loops of small bowel, but there were minimal bowel adhesions per se. The patient was rotated to his left side and placed in Trendelenburg. The cecum was identified and grasped. The terminal ileum was identified and was noted to be completely decompressed as opposed to the dilated remainder of the small bowel. The terminal ileum was traced proximally and medially it was noted to extend down into the pelvis. Attempts were made laparoscopically to dissect away the adhesions down in the pelvis, but they were densely involving several loops of small bowel and could not be safely manipulated with the laparoscopic instruments because of those dense adhesions. For that reason, after about an hour of lysing adhesions and attempting to resolve the problem laparoscopically, the laparoscopic approach was abandoned. The patient had previously had a Pfannenstiel incision, and this was re-entered incising into the skin and subcutaneous tissue and elevating the rectus fascia off the rectus muscles. An incision was then made between the rectus muscles into the peritoneal cavity. A wound barrier Alexis was then placed into the wound. Exposure was obtained. The dilated small bowel was packed away. Exposure was obtained of the pelvis. With sharp dissection and with blunt fingertip dissection, the adhesions in the pelvis were broken up, and the small bowel was dissected out of the pelvis entirely.
The distal ileum at the transition zone was twisted into a dense stricture at this location. In order to resolve that obstruction,it was elected to perform a partial enterectomy. Approximately 6 cm of mid to distal ileum were displayed. The mesentery was clamped, incised and ligated, clamping off the vascular inflow. A portion of ileum was then resected between the distal decompressed ileum and the proximal dilated ileum utilizing the GIA stapling device. This specimen was sent to the pathologist for review. An immediate anastomosis was then performed. An opening was made into each limb, the proximal and distal limb of the ileum, and a limb of the GIA stapling device was placed into each limb and fired, creating a functional end-to-end enterostomy. The resultant opening was then closed with another firing of the GIA stapling device, completing the anastomosis. The mesenteric defect was closed with interrupted 3-0 Vicryl sutures. With reconstitution of the small bowel continuity and resolution of the obstruction, the small bowel was then packed cephalad and the pelvis was examined. A small pocket of purulent material had been encountered during the dissection. Initially this was felt to represent an enterotomy, but it was discovered to be a small abscess. It was effectively drained and debrided. The pelvis was irrigated. The sigmoid was examined and appeared to be normal with no evidence of induration or feculent leakage. However, with palpation of the sigmoid colon down to the previous low rectal anastomosis, there was noted to be fingertip defect at the anastomosis directly posteriorly. This could not be visualized or accessed easily through the abdominal approach because the anastomosis was intact anteriorly and the posterior wall could not be manipulated or visualized. Since the anastomosis was low down, just above the dentate line, it was felt that a rectal approach might provide better access to the defect. The patient was reprepped and draped and placed in lithotomy position. The rectum was dilated and a rectal retractor was placed. The defect could be palpated just above the dentate line and just above the staple line posteriorly. It was closed with interrupted sutures of 2-0 Vicryl through and through the mucosa and serosa, placed transversely, first through the cephalad margin of the anastamosis and then through the caudad margin of the anastomosis. These sutures were placed individually and then tied snugly, completely closing the disrupted anastomotic defect. This repair was palpated and there was no further defect noted. It was irrigated and there was no leakage noted into the pelvis. A finger was then placed up to the anastomosis, and the operator's finger could easily be placed through the anastomosis up into the more proximal bowel. The anastomosis was felt to be widely patent and now securely closed. However, because of the tenuous nature of the closure, it was felt prudent to perform a diverting stoma proximally. The rectum was redraped. The operating surgeon changed gown and gloves and returned to the abdomen. The pelvis was copiously irrigated. The small bowel was examined, and the anastomosis was noted to be intact and viable. A hand was then placed through the Pfannenstiel incision and a loop of transverse colon was palpated and placed up against the anterior abdominal wall in the patient's right upper quadrant. A circular portion of skin was excised in the patient's right upper quadrant along the lateral edge of the rectus muscle. An incision was then made into the anterior rectus fascia in a cruciate fashion, and the rectus muscles were split and the posterior rectus fascia was opened. The stoma was dilated to 3 fingerbreadths. The loop of transverse colon was then pulled up and out through this incision easily under no tension. An opening was made into the mesentery, and a bridge was placed through the mesentery and secured to the skin with interrupted silk sutures supporting the loop of colon at the skin level. The wound was again irrigated. Hemostasis was noted. A 10 mm Jackson-Pratt drain was placed into the pelvis and was exited through a stab incision in the left lower quadrant, connected to the skin with silk sutures and connected to bulb suction. The wound fascia was then closed with a running 0 PDS suture. The wound was again irrigated. The skin incisions were closed with interrupted staples loosely placed. The stoma was then matured. The bowel was opened transversely anteriorly, and the serosal and mucosal edges were then rotated back and secured to the dermis with interrupted sutures of 3-0 chromic, maturing the colostomy. A finger was placed into both the distal and proximal limb and they were widely patent. The colostomy was noted to be supported by the bridge with no tension on the stoma itself. The abdominal skin was then cleaned. A stoma device/bag was placed over the stoma itself. The wound was dressed sterilely. The patient tolerated the entire procedure well. There were no operative complications. Blood loss was minimal. Specimen consisted of portion of ileum. The patient was taken to the Postanesthesia Care Unit in good condition.
The doctor has given codes 44120, 44320, 45562 and 44005. I know the 44005 is out but I am not sure if the 45562 is the correct code for the repair of the anastomosis, but I can't find anything else for a repair done with a rectal approach. Any help would be wonderful!
Thanks,
MATERIAL FORWARDED TO LAB: Portion of ileum.
FINDINGS: The patient was noted to have moderately dilated small bowel to the mid ileum. A loop of mid ileum was densely adhesed into the low pelvis alongside his previous low coloproctostomy anastomosis. There was a small abscess in the pelvis covered over by the small bowel. The patient was also noted to have a fingertip sized opening in the posterior aspect of his anastomosis at the staple line, deep in his pelvis just above the dentate line in the rectum. This is presumed to be present from the original surgery on 02/11/2013. It was felt to be the source of the original purulent drainage. It was felt likely to be patched over by the loop of distal ileum which was densely adhered into the pelvis and was effectively patched; however, it caused the high-grade partial bowel obstruction. Throughout the remainder of the abdomen there were minimal adhesions but diffusely dilated small bowel. The colon itself was not dilated but appeared grossly normal, other than at the anastomosis posteriorly. It was difficult but not impossible to approach the posterior aspect of the low pelvic anastomosis from the abdominal side. It was approachable through the rectum and was repaired through the rectum for that reason. Diverting colostomy was performed to divert the stream away from the repaired anastomosis in hopes of it healing without further leakage.
PROCEDURE: The patient was taken to the main operating room, given general anesthesia, and prepped and draped in a sterile fashion. Initial entry into the abdomen was made through a 5 mm incision in the left upper quadrant at the costal margin. A Veress needle was inserted, and the abdomen was insufflated with CO2. A 5 port was then placed bluntly into through that incision using the Optiview to technique. The abdominal cavity was entered. Laparoscope was placed down through this port. The omentum was noted to be densely adherent to the anterior abdominal wall. It was bluntly taken down with the laparoscope revealing access to the anterior abdominal wall on the patient's left side. Another 5 port was placed in the left hypogastrium and a third 5 port was placed in the left lower quadrant bluntly penetrating through the abdominal wall under direct vision. With these ports in place and with blunt dissection, the omentum was taken down off the abdominal wall, allowing exposure to the abdominal cavity. Visualization revealed markedly dilated loops of small bowel, but there were minimal bowel adhesions per se. The patient was rotated to his left side and placed in Trendelenburg. The cecum was identified and grasped. The terminal ileum was identified and was noted to be completely decompressed as opposed to the dilated remainder of the small bowel. The terminal ileum was traced proximally and medially it was noted to extend down into the pelvis. Attempts were made laparoscopically to dissect away the adhesions down in the pelvis, but they were densely involving several loops of small bowel and could not be safely manipulated with the laparoscopic instruments because of those dense adhesions. For that reason, after about an hour of lysing adhesions and attempting to resolve the problem laparoscopically, the laparoscopic approach was abandoned. The patient had previously had a Pfannenstiel incision, and this was re-entered incising into the skin and subcutaneous tissue and elevating the rectus fascia off the rectus muscles. An incision was then made between the rectus muscles into the peritoneal cavity. A wound barrier Alexis was then placed into the wound. Exposure was obtained. The dilated small bowel was packed away. Exposure was obtained of the pelvis. With sharp dissection and with blunt fingertip dissection, the adhesions in the pelvis were broken up, and the small bowel was dissected out of the pelvis entirely.
The distal ileum at the transition zone was twisted into a dense stricture at this location. In order to resolve that obstruction,it was elected to perform a partial enterectomy. Approximately 6 cm of mid to distal ileum were displayed. The mesentery was clamped, incised and ligated, clamping off the vascular inflow. A portion of ileum was then resected between the distal decompressed ileum and the proximal dilated ileum utilizing the GIA stapling device. This specimen was sent to the pathologist for review. An immediate anastomosis was then performed. An opening was made into each limb, the proximal and distal limb of the ileum, and a limb of the GIA stapling device was placed into each limb and fired, creating a functional end-to-end enterostomy. The resultant opening was then closed with another firing of the GIA stapling device, completing the anastomosis. The mesenteric defect was closed with interrupted 3-0 Vicryl sutures. With reconstitution of the small bowel continuity and resolution of the obstruction, the small bowel was then packed cephalad and the pelvis was examined. A small pocket of purulent material had been encountered during the dissection. Initially this was felt to represent an enterotomy, but it was discovered to be a small abscess. It was effectively drained and debrided. The pelvis was irrigated. The sigmoid was examined and appeared to be normal with no evidence of induration or feculent leakage. However, with palpation of the sigmoid colon down to the previous low rectal anastomosis, there was noted to be fingertip defect at the anastomosis directly posteriorly. This could not be visualized or accessed easily through the abdominal approach because the anastomosis was intact anteriorly and the posterior wall could not be manipulated or visualized. Since the anastomosis was low down, just above the dentate line, it was felt that a rectal approach might provide better access to the defect. The patient was reprepped and draped and placed in lithotomy position. The rectum was dilated and a rectal retractor was placed. The defect could be palpated just above the dentate line and just above the staple line posteriorly. It was closed with interrupted sutures of 2-0 Vicryl through and through the mucosa and serosa, placed transversely, first through the cephalad margin of the anastamosis and then through the caudad margin of the anastomosis. These sutures were placed individually and then tied snugly, completely closing the disrupted anastomotic defect. This repair was palpated and there was no further defect noted. It was irrigated and there was no leakage noted into the pelvis. A finger was then placed up to the anastomosis, and the operator's finger could easily be placed through the anastomosis up into the more proximal bowel. The anastomosis was felt to be widely patent and now securely closed. However, because of the tenuous nature of the closure, it was felt prudent to perform a diverting stoma proximally. The rectum was redraped. The operating surgeon changed gown and gloves and returned to the abdomen. The pelvis was copiously irrigated. The small bowel was examined, and the anastomosis was noted to be intact and viable. A hand was then placed through the Pfannenstiel incision and a loop of transverse colon was palpated and placed up against the anterior abdominal wall in the patient's right upper quadrant. A circular portion of skin was excised in the patient's right upper quadrant along the lateral edge of the rectus muscle. An incision was then made into the anterior rectus fascia in a cruciate fashion, and the rectus muscles were split and the posterior rectus fascia was opened. The stoma was dilated to 3 fingerbreadths. The loop of transverse colon was then pulled up and out through this incision easily under no tension. An opening was made into the mesentery, and a bridge was placed through the mesentery and secured to the skin with interrupted silk sutures supporting the loop of colon at the skin level. The wound was again irrigated. Hemostasis was noted. A 10 mm Jackson-Pratt drain was placed into the pelvis and was exited through a stab incision in the left lower quadrant, connected to the skin with silk sutures and connected to bulb suction. The wound fascia was then closed with a running 0 PDS suture. The wound was again irrigated. The skin incisions were closed with interrupted staples loosely placed. The stoma was then matured. The bowel was opened transversely anteriorly, and the serosal and mucosal edges were then rotated back and secured to the dermis with interrupted sutures of 3-0 chromic, maturing the colostomy. A finger was placed into both the distal and proximal limb and they were widely patent. The colostomy was noted to be supported by the bridge with no tension on the stoma itself. The abdominal skin was then cleaned. A stoma device/bag was placed over the stoma itself. The wound was dressed sterilely. The patient tolerated the entire procedure well. There were no operative complications. Blood loss was minimal. Specimen consisted of portion of ileum. The patient was taken to the Postanesthesia Care Unit in good condition.
The doctor has given codes 44120, 44320, 45562 and 44005. I know the 44005 is out but I am not sure if the 45562 is the correct code for the repair of the anastomosis, but I can't find anything else for a repair done with a rectal approach. Any help would be wonderful!
Thanks,