Imperforate Anus; Malrotation


Palmer, AK
Best answers
I could sure use some advice in coding this surgery. So far, I feel I should use: 44345 -63
32551 -63, -51, -LT.

Procedure: ) 1) exam under anesthesia 2) exploratory laparoscopy (aborted) 3 exploratory laparotomy 3) divided colostomy with mucous fistula 4) re-opening of laparotomy 5) colon resection X1 and 6) revision of colostomy and mucous fistula 7) chest tube placement, left tube thoracostomy

Indications: Girl_____ is a 1 days female presenting with ambiguous genitalia and imperforate anus. Ford details, please consult note. I apprised dad to the risks and benefits of the procedure and they requested that I proceed. Weight: 2.71 kg (5 lb 15.6 oz) (Filed from Delivery Summary)

Operative Details: Girl_____ was brought to the operating room where she underwent general anesthesia. Girl_____was then prepped and draped in the usual fashion. An infraumbilical incision was made and a 3 mm trocar introduced directly into the peritoneal cavity which was insufflated to 8 mm Hg. Anesthesia was concerned about lung volumes quickly and placement of the scope was not helpful with the amount of bowel dilation. I aborted laparoscopy quickly. A left lower quadrant incision was made and the dilated dista colon delivered into the wound. The distal limb was followed into the pelvis. A left tube and streak ovary were identified. There was no obvious right gonad. I saw no evidence of hydrocolpos but the dilated rectum completely filled the pelvis. The dilated colon was making visualization difficult even with a large incision. I made an enterotomy with the intent of using this segment for the colostomy. The colon was evacuated and a large amount of air and liquid stool returned. After decompression, The enterotomy was a bit more distal than I wanted for the divided stoma. I closed the enterotomy with interrupted 3-0 vicryl sutures and traced the bowel back to what I assumed was the proximal sigmoid. This was sutured to the the lateral edge of the wound after the colon was divided over a mesenteric window. The fascia was closed between the proximal(lateral) and distal (medial/mucous fistula) using interrupted 3-0 vicryl sutures. The skin was closed with interrupted 5-0 monocryl placed in a subcuticular fashion. The stomas were then matured with 3-0 vicryl. I began to irrigate the mucous fistula and was not getting anything to return. At this point, anesthesia was experiencing difficulties with saturations and blood pressure. I was concerned that her abdomen was a bit more distended and that the approximately 100 mL did not return. I re-opened her incision a small amount of fluid returned and this did not really help anesthesia. However It was evident that the red rubber catheter exited between two of my vicryl sutures in the enterotomy closure. Given the extremis of the baby, I made the decision to resect resect this small section rather than repair it. The bowel was transected with electrocautery and passed it off the field. I noted a this point that the right colon and appendix were eviscerated and clearly not fixed. I placed a retractor and indeed the entire colon was mobile and the ligament of trietz was clearly in the right upper quadrant. At this point, the baby was not in a condition for an elective ladd's procedure. The proximal lumen was sutured to the lateral edge of the wound and the facia closed between the stoma and mucous fistual using interrupted 3-0 vicryl sutures. The intervening skin was closed with interrupted monocryl and the stomas matured just above skin level with vicryl. In discussion with anesthesia, a CXR was ordered and clearly showed a left pneumothorax. I quickly prepped and draped the left chest and placed a 12 FR thoracostomy tube in the 5th intercostal space with the return of air and serous fluid. The chest tube was secured with a 3-0 prolene suture and placed to -10 cm water. The tube was dressed with telfa and tegaderm. The baby was taken to the NICU in critical condition.

Any help and/or advice in coding this surgery will be sincerely appreciated.