Laparoscopic Cecectomy


Helena, AL
Best answers
What CPT code should I use for a laparoscopic cecectomy for the removal of a lesion/polyps? Our office had originally chosen 44110 until we noticed that it was for an open procedure.

1. Second look laparoscopy for ovarian cancer with collection of peritoneal
cytology and removal of peritoneal implants and partial omentectomy.
2. Laparoscopic cholecystectomy with intraoperative cholangiogram.
3. Ileal colostomy with partial colectomy and resection of terminal ileum.

SPECIMENS: Peritoneal implants. Peritoneal cytology. Gallbladder and its
contents. Portion of terminal ileum. Portion of colon. Portion of omentum.

INDICATIONS: The patient female who has history of ovarian
cancer. She has undergone a radical hysterectomy with debulking, also a
rectosigmoid resection and right hemicolectomy. She is here for reversal of
colostomy, second look laparoscopy and cholecystectomy.

DESCRIPTION: After informed consent was obtained, preoperative antibiotics, as
well as subcutaneous heparin were administered within the hour of the
procedure per protocol. . General endotracheal anesthetic was
applied. Sequential compression devices were in place and functioning at time
of induction. All pressure points were padded. A surgical time-out was
performed per CMS guidelines. Her abdomen was prepped and draped in normal
sterile fashion with the Op-Site covering her ileostomy.

Initially a Veress needle was placed in the left upper quadrant. A 2 liter
pneumoperitoneum was created and a 5 mm trocar was then inserted. Inspection
of the abdomen showed an endoileostomy with a small hernia around the stoma,
or a parastomal hernia and multiple implants throughout the abdomen. A 12 mm
port and 2 right subcostal 5 mm ports were placed. Attention was initially
directed towards collection of the specimens. Multiple small little nodules
were noted throughout the stomach, the gastrohepatic ligament, as well as the
bed of the gallbladder. The liver was otherwise unremarkable. There was
evidence of a long mucus fistula with the hepatic flexure to the descending
colon remaining intact. There was no pelvic lesions. As many implants as
could be submitted were submitted, some for frozen and some for permanent and
all the initial pathology returned negative for malignancy.

The abdomen was filled with a liter of saline. There was a 5 minute dwell
time and then the fluid was aspirated and sent for cytology. Upon completion
of this the gallbladder was taken down in a dome down fashion until I got to
the level of the cystic artery. It was doubly clipped and divided. The
cystic duct was skeletonized. The duct itself was approximately 4 cm in
length. It was cannulated with a cholangiogram catheter and under
fluoroscopic interrogation there was sluggish flow through a mildly dilated
common bile duct, but it eventually went into the duodenum without difficulty.
The proximal biliary radicles were nondilated and there was no evidence of
strictures or other lesions, or any filling defects within the common bile or
common hepatic duct.

With that in mind the cholangiogram catheters were removed, 2 clips were
placed on the cystic duct stump. Bovie cautery was applied delicately to the
end of the cystic duct to prevent postoperative leakage. The gallbladder bed
was inspected and was hemostatic. The gallbladder was then placed in the
left upper quadrant for later retrieval.

This being done, the 12 mm port was closed at the fascial layer using #0
Vicryl suture. I then cored out the ileostomy down to the level of the
fascia. I mobilized the entire remaining right colon off of the duodenum and
off Gerota's fascia taking care to prevent ureteral or vascular injury.
After having satisfactory length, I then mobilized the entire ileostomy. I
pulled the ileostomy out through the ileostomy incision and freshened up the
end resecting approximately 3 mm of terminal ileum. I then pulled up the
colon through the same incision and repeated the procedure. I removed the
gallbladder through the incision where the ileostomy was, passed this off the
field. I then created an end-to-end functional side-to-side anastomosis,
placing GI pop-off silk sutures on the intermesenteric portions of the small
bowel and the colon after ensuring there was no twist in the bowel.

With this being done, I then opened the colon and small bowel, placed an
endo-GIA 6 mm white load, advanced it, locked and fired it, creating a linear
stapled ileocolostomy. Three GI pop-off silks were then used to temporarily
close the common enterotomy and this was then closed with the stapling
device. The mesenteric defect was likewise closed with a series of
interrupted silk sutures. I then placed the entire anastomosis into the
peritoneal cavity and closed the fascia with a looped #1 PDS suture tied upon
itself. Having completed this, all wounds were copiously irrigated with
saline and then Betadine. The fascia sutures at the 12 mm port site were
closed. The skin incisions were again copiously irrigated with saline and
Betadine. The ileostomy site was loosely reapproximated with a stapling
device with Telfa placed as wicks and the laparoscopic sites were closed with
4-0 Vicryl. Mastisol, Steri-Strips and planes were then applied. She was
then awoken from anesthesia, extubated and transferred to the recovery room in
stable condition, having tolerated the procedure quite nicely.
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Am I wrong or did this patient have a previous ileostomy and the surgeon now reversed it? I see a resection and anastomosis with closure of the skin level ileostomy site. If this is the case, I'd look at 44227. Other thoughts?