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lap assisted sigmoid colectomy

lovetocode

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When you have time, will someone please review this op report and tell me how you would code? I looking at 44204 and 44207. It seems I have documentation for low pelvic anastomosis, but I would like someone to take a look at it. Thanks so much in advance.

PREPROCEDURE DIAGNOSIS:
Recurrent sigmoid diverticulitis.

POSTPROCEDURE DIAGNOSIS:
Recurrent sigmoid diverticulitis.

PROCEDURE PERFORMED:
Laparoscopic-assisted sigmoid colectomy with takedown of splenic flexure.

CO-SURGEON:
Dr. X necessary because of the difficulty of the case.

ANESTHESIA:
General endotracheal, Atlantic.

ESTIMATED BLOOD LOSS:
Minimal.

TUBES AND DRAINS:
None.

SPECIMEN:
Sigmoid colon.

COMPLICATIONS:
None.

INDICATIONS FOR PROCEDURE:
This obese 83-year-old lady was quite active, had laparoscopic cholecystectomy
by me in the past. She has had 2 episodes of outpatient diverticulitis 3 years
ago, requiring oral antibiotics and she had a severe attack of diverticulitis,
requiring oral antibiotics with mild inflammation documented around the sigmoid
colon in early 2011. Subsequent colonoscopy by Dr. Dandalides showed left
colon and sigmoid diverticulosis. She had a recent attack on November 4, 2011
of diverticulitis, treated with outpatient antibiotics. CT scan also showed
mild pericolonic sigmoid inflammation at that time. Because of her recurrent
attack, she was taken to the operative theater for laparoscopic-assisted
sigmoid colectomy.

DESCRIPTION OF PROCEDURE:
The patient was placed on operating table in supine position. Appropriate time-
out was done. IV Mefoxin was given on-call to the operating theater and will
be discontinued within 24 hours as per PQRI protocol. After induction of
general endotracheal anesthesia, Foley catheter was placed as well as Kendall
stockings and an orogastric tube. The abdomen and perineum were prepped and
draped in the appropriate sterile fashion. The patient was positioned in Lloyd
Davies stirrups. After appropriately prepping and draping, we made a 6-cm
incision just above the umbilicus in the midline. This was extended through
the skin and subcutaneous tissue. Linea alba was incised. The preperitoneal
cavity was entered. There was some omental adhesions to the previous umbilical
trocar incision and these were taken down. Small bleeders in the omentum were
controlled with electrocautery. There appeared to be good hemostasis. There
was a small fascial defect in the umbilicus, which we repaired internally with
a single suture of 0-Vicryl. We placed the GelPort in the wound with a 12
trocar and the abdomen was insufflated with CO2 gas, 14 mmHg pressure.
Following this, the videoscopic laparoscope was inserted. Laparoscopic
inspection revealed a large fatty omentum and a very large fatty mesentery of
the left colon and sigmoid colon. The operation was quite tedious because of
the patient's marked abdominal adiposity. We were able to carefully identify
structures and had fairly good hemostasis throughout the procedure. The
operative field was dry at the end of the case. We mobilized the white line of
Toldt. There was some inflammatory adhesions to the pelvic sidewall. The
patient had two atrophic ovaries, which were identified and preserved. The
white line of Toldt was incised up to the splenic flexure. The splenic flexure
was taken down with the LigaSure instrument. We mobilized the left colon away
from the left gutter and the left kidney. The ureter was identified and
preserved throughout the dissection on the left side and we did not injured on
the right side either. We dissected down into the pelvis and into the
retrorectal space. We scored the mesentery in each side of the upper rectum
and divided the rectum low in the pelvis beneath the sacral promontory. We
divided the rectum after creating a clear space between the rectum and the
mesentery in the rectum and then we placed an articulating Endo GIA 60 triple
level stapler and divided the bowel. There was some mesentery laterally, which
we also divided with a stapling device. The bowel had been closed with one
staple device. There appeared to be good bleeding at the stapled end and we
appeared to have had a nice secure closure of the rectal stump. We then
divided the mesentery with the Endo GIA articulating 45 gold stapler. We
divided the inferior mesenteric with a Endo-GIA articulating gold stapler. We
took some sigmoidal vessels as well with the Endo GIA 45 articulating gold
stapler. There was excellent hemostasis after having mobilized the splenic
flexure. The bowel would reach nicely in the pelvis without undue tension
after removing the sigmoid colon. As mentioned above, the ureters were
identified and preserved. At this point, we brought out the specimen through
the hand port incision and desufflated the abdomen. We selected a point of
division between the lower left colon and sigmoid colon where the bowel was
nice and soft and away from the thickened sigmoid colon. We divided the
mesentery at that level with the LigaSure instrument and then we divided the
left colon with the pursestring instrument. We reinforced the pursestring with
an additional 0 Vicryl suture and we cleaned the fat off of the bowel serosal
surface. We then returned the proximal colon to the abdominal cavity. It
should be mentioned that we had dilated this up quite nicely, so that we will
accept the anvil of the 29 ILS stealth stapler. We returned this to the
abdominal cavity. The hand port was replaced. We re-insufflated the abdominal
cavity. We once again inspected and there was excellent hemostasis. We then
dilated the rectum. Dr. Boustany broke away from the top of the table and went
below. He dilated the rectum up to the 29 dilator without any problem and he
placed the 29 ILS stealth stapler into the rectum and opened it, flushed
against the rectal stump, centering this right below the staple line in the
middle. This was opened up and then made it with the proximal bowel snap down
and crank down and the stapler was fired. There were 2 excellent complete
rings after the stapler had been removed and these were inspected and
identified off of the table. I then occluded the bowel proximally and Dr.
Boustany was able to visualize an intact anastomosis with the proctoscope and
also insufflated the rectum with the upper bowel occluded manually by me and
with the pelvis filled with saline. We saw no bubbles and no obvious leak. We
desufflated the rectum. The scope was removed. We inspected the lateral
gutter as well as the pelvis and there appeared to be excellent hemostasis. We
then brought the omentum down over the viscera. All trocars removed as well as
the hand port. There had been a right lower quadrant 10/12 trocar placed under
direct vision as well as the midline suprapubic trocar 10/12 nonbladed placed
under direct vision as well as a left lateral 10/12 nonbladed trocar which had
been placed under direct vision and were utilized throughout the operation with
the camera and dissecting instrumentation. As these were nonbladed ports, we
did not close the fascia. We did close the hand port fascia with 2 double
looped #1 PDS sutures which were started from the apex of the wounds and tied
securely in the midline. The wounds were irrigated with sterile saline
solution. The wounds were closed with approximate staples followed by Xeroform
and a sterile dressing. Sponge and needle counts were correct x2. The
pathologist did open the specimen off the table and all appeared consistent
with chronic recurrent diverticulitis.
 
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