maine4me
Guru
I am hoping someone can look at this operative report and give me a clue about how to code it. I have been staring at this section of the CPT book for what seems like hours, and just cannot determine the code(s). 
PREOPERATIVE DIAGNOSIS: Small bowel obstruction with newly identified 7 cm right
abdominal mass involving mesentery of small versus large bowel.
POSTOPERATIVE DIAGNOSIS: Same with involvement of terminal ileum right at insertion into
colon as well as a secondary involvement of more proximal jejunum.
PROCEDURES:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Extended right hemicolectomy with partial omentectomy and portion of transverse colon
serosa with primary repair.
4. Small bowel enterectomy with side-to-side, functional end-to-end enteroenterostomy
from proximal jejunal involvement.
ANESTHESIA: General endotracheal.
FINDINGS: The patient had an isolated bulky but mobile mass in the right side of her
abdomen with a fair amount of adhesions in and around it and involvement of more proximal
jejunum as described above. This necessitated two separate bowel resections once fully
mobilized and included a right hemicolectomy whereby a 3 cm involvement of the transverse
colon serosa was taken off and then the serosal defect was closed primarily and a portion
of omentum emanating off the right side was left attached to it. A secondary site of
involvement was more proximal jejunum which appeared to have adherence to a nodule that
unfortunately broke free during the dissection and was taken separately. There was no
gross tumor spread anywhere encountered in the peritoneal cavity and no spillage of tumor
during the procedure. Adhesions were taken down from the ligament of Treitz all the way
down to the new newly formed ileal colostomy. Both bowel anastomoses were side-to-side,
functional, end-to-end stapled anastomoses with closure of the mesenteric defect. The
liver, which could only be palpated on either side of adhesions left over from the prior
cholecystectomy, was free of palpable abnormalities.
INDICATIONS: The patient is a 102-year-old woman with excellent performance status, who
was ambulatory and mentally quite sharp. She presented to the ER with signs and symptoms consistent with bowel obstruction. On admission, CT scan was
identified as having a 6.1 x 8 x 5.6 cm enhancing mass in the distal ileum and proximal
cecum. This was the obvious cause of her small bowel obstruction proximally. Options
were discussed with the patient and family, who elected to proceed with surgical
exploration to alleviate the bowel obstruction and treat the mass if possible.
Preoperatively, the risks and benefits of the procedure were discussed with the patient.
PROCEDURE IN DETAIL: Following general endotracheal anesthesia, the patient had an
indwelling Foley catheter placed. Her abdomen was prepped with Hibiclens and draped in
the usual sterile fashion. Through a midline celiotomy of approximately 15 cm in length,
the abdomen was explored. There were adhesions to her lower midline incision from prior
pelvic surgery that were taken down sharply. There were also adhesions over to the right
side in the vicinity of the palpable mass, which were taken down sharply until the
omentum was divided with the Harmonic Scalpel and serial clamps and ties as necessary.
Following lysis of adhesions all the way down to the pelvis that included exclusively
small bowel, the mass involving the mesentery and terminal ileum right where it inserts
in the cecum was mobilized to the midline and resected in the form of a right
hemicolectomy that necessitated a small portion of serosa coming off of the transverse
colon due to involvement of the tumor. There was no through-and-through enterotomy at
this location and the serosal defect was closed with interrupted 3-0 silk sutures. A
formal right hemicolectomy was performed with a portion of omentum that was left attached
to the mass by dividing the mesentery between serial clamps and ties as well as using the
Harmonic Scalpel until the ileum and colon could be approximated with interrupted 3-0
silk sutures to line up and then a stapled GIA 75 blue load side-to-side, functional
end-to-end anastomosis could be performed with oversewing where the staple lines crossed.
Mesenteric defect was closed with interrupted 3-0 silk sutures.
In the process of mobilization of this mass, it was obvious that a second portion of
bowel was involved with some nodular tumor left on the mesentery just below the bowel.
This was in the proximal jejunum approximately 20 to 30 cm distal to the ligament of
Treitz. Once fully mobilized and adhesions lysed, it was obvious that this only required
a 10 cm resection and as such was performed in the same manner as previously dictated for
the other with a side-to-side, functional end-to-end stapled anastomosis. This allowed
the small bowel to be run from the ligament of Treitz all the way down to the newly
formed ileocolonic anastomosis. There were no other findings present. The pelvis was
palpated and although had stool in it, there was no mass and no retroperitoneal
lymphadenopathy encountered. The right ureter was not dissected nor observed in the
process of the operation.
The midline fascia was ultimately closed following irrigation of the abdomen with 2
liters of sterile saline containing antibiotics. There was no stool spillage and this
case should therefore be considered a clean case. The midline fascia was closed with
running #1 PDS tied at either end and knotted in the middle. Subcutaneous tissues were
irrigated and the skin edges were approximated with skin staples. The patient was
extubated in the Operating Room and transferred to the ICU for immediate postoperative
recovery. She remained hemodynamically stable throughout the entire procedure and
necessitated no transfusion. Estimated blood loss was per anesthesia.
PREOPERATIVE DIAGNOSIS: Small bowel obstruction with newly identified 7 cm right
abdominal mass involving mesentery of small versus large bowel.
POSTOPERATIVE DIAGNOSIS: Same with involvement of terminal ileum right at insertion into
colon as well as a secondary involvement of more proximal jejunum.
PROCEDURES:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Extended right hemicolectomy with partial omentectomy and portion of transverse colon
serosa with primary repair.
4. Small bowel enterectomy with side-to-side, functional end-to-end enteroenterostomy
from proximal jejunal involvement.
ANESTHESIA: General endotracheal.
FINDINGS: The patient had an isolated bulky but mobile mass in the right side of her
abdomen with a fair amount of adhesions in and around it and involvement of more proximal
jejunum as described above. This necessitated two separate bowel resections once fully
mobilized and included a right hemicolectomy whereby a 3 cm involvement of the transverse
colon serosa was taken off and then the serosal defect was closed primarily and a portion
of omentum emanating off the right side was left attached to it. A secondary site of
involvement was more proximal jejunum which appeared to have adherence to a nodule that
unfortunately broke free during the dissection and was taken separately. There was no
gross tumor spread anywhere encountered in the peritoneal cavity and no spillage of tumor
during the procedure. Adhesions were taken down from the ligament of Treitz all the way
down to the new newly formed ileal colostomy. Both bowel anastomoses were side-to-side,
functional, end-to-end stapled anastomoses with closure of the mesenteric defect. The
liver, which could only be palpated on either side of adhesions left over from the prior
cholecystectomy, was free of palpable abnormalities.
INDICATIONS: The patient is a 102-year-old woman with excellent performance status, who
was ambulatory and mentally quite sharp. She presented to the ER with signs and symptoms consistent with bowel obstruction. On admission, CT scan was
identified as having a 6.1 x 8 x 5.6 cm enhancing mass in the distal ileum and proximal
cecum. This was the obvious cause of her small bowel obstruction proximally. Options
were discussed with the patient and family, who elected to proceed with surgical
exploration to alleviate the bowel obstruction and treat the mass if possible.
Preoperatively, the risks and benefits of the procedure were discussed with the patient.
PROCEDURE IN DETAIL: Following general endotracheal anesthesia, the patient had an
indwelling Foley catheter placed. Her abdomen was prepped with Hibiclens and draped in
the usual sterile fashion. Through a midline celiotomy of approximately 15 cm in length,
the abdomen was explored. There were adhesions to her lower midline incision from prior
pelvic surgery that were taken down sharply. There were also adhesions over to the right
side in the vicinity of the palpable mass, which were taken down sharply until the
omentum was divided with the Harmonic Scalpel and serial clamps and ties as necessary.
Following lysis of adhesions all the way down to the pelvis that included exclusively
small bowel, the mass involving the mesentery and terminal ileum right where it inserts
in the cecum was mobilized to the midline and resected in the form of a right
hemicolectomy that necessitated a small portion of serosa coming off of the transverse
colon due to involvement of the tumor. There was no through-and-through enterotomy at
this location and the serosal defect was closed with interrupted 3-0 silk sutures. A
formal right hemicolectomy was performed with a portion of omentum that was left attached
to the mass by dividing the mesentery between serial clamps and ties as well as using the
Harmonic Scalpel until the ileum and colon could be approximated with interrupted 3-0
silk sutures to line up and then a stapled GIA 75 blue load side-to-side, functional
end-to-end anastomosis could be performed with oversewing where the staple lines crossed.
Mesenteric defect was closed with interrupted 3-0 silk sutures.
In the process of mobilization of this mass, it was obvious that a second portion of
bowel was involved with some nodular tumor left on the mesentery just below the bowel.
This was in the proximal jejunum approximately 20 to 30 cm distal to the ligament of
Treitz. Once fully mobilized and adhesions lysed, it was obvious that this only required
a 10 cm resection and as such was performed in the same manner as previously dictated for
the other with a side-to-side, functional end-to-end stapled anastomosis. This allowed
the small bowel to be run from the ligament of Treitz all the way down to the newly
formed ileocolonic anastomosis. There were no other findings present. The pelvis was
palpated and although had stool in it, there was no mass and no retroperitoneal
lymphadenopathy encountered. The right ureter was not dissected nor observed in the
process of the operation.
The midline fascia was ultimately closed following irrigation of the abdomen with 2
liters of sterile saline containing antibiotics. There was no stool spillage and this
case should therefore be considered a clean case. The midline fascia was closed with
running #1 PDS tied at either end and knotted in the middle. Subcutaneous tissues were
irrigated and the skin edges were approximated with skin staples. The patient was
extubated in the Operating Room and transferred to the ICU for immediate postoperative
recovery. She remained hemodynamically stable throughout the entire procedure and
necessitated no transfusion. Estimated blood loss was per anesthesia.