LAR vs protectomy??

Oklahoma City, OK
Best answers
New to coding and need help please!!! I was thinking 45120???

After informed consent was obtained, the patient was brought to Weinberg main OR 6 and placed in supine position.* Cardiopulmonary monitors were placed by anesthesia and vital signs were stable.* General endotracheal anesthesia was smoothly induced.* The patient's right upper extremity was tucked to the side and the left upper extremity was placed at a 75-degree angle to the body.* All pressure points were properly padded. The patient was converted from supine position to lithotomy position.* Perioperative antibiotics and subcutaneous heparin were given.* The patient was prepped and draped in usual sterile fashion.* A multidisciplinary time-out was performed to confirm the patient's identity and procedure performed.

The drapes were taken down.* A rectal washout was performed.* The patient was prepped and draped in usual sterile fashion for my portion of the procedure.* A multidisciplinary time-out was performed for my portion of the procedure.

Using the cut mode of electrocautery, a 10 mm longitudinal supraumbilical incision was created.* The adipose tissue was spread and the fascia was grasped with 2 Kocher clamps.* The fascia was incised using a #15 blade knife.* It was secured with an 0-Vicryl suture and then later on with a #1 PDS suture U-stitch.* A 10/12 port was then placed through the supraumbilical port site and the abdomen was insufflated to 15 mmHg carbon dioxide pneumoperitoneum.* When the patient was placed in Trendelenburg position, then his peak pressures increased and thus we decreased the intraabdominal pressure to 11 mmHg carbon dioxide pneumoperitoneum.* A 10 mm 30-degree laparoscopic was used to gain access into the abdomen and there was no injury to the underlying structures.* The abdomen was explored and there was no evidence of liver or peritoneal implants from the cancer.* The laparoscopic ports were placed under direct visualization as follows:* Three 5-mm ports in the right upper, right lower, and left lower quadrants.* The patient was placed in Trendelenburg position with right side down.* The sigmoid colon was raised to the anterior abdominal wall.* Peritoneal incision was created from the sacral promontory to the inferior mesenteric artery.* A medial to lateral dissection was performed and the left ureter was very maculating within.* The field was then protected from harm's way.* The inferior mesenteric artery was taken as a high ligation using the laparoscopic blunt-tip LigaSure.* The rest of the medial to lateral dissection was performed.*** The white line of Toldt was incised to mobilize the sigmoid colon and descending colon.* The omentum was taken down and the gastrocolic ligament was incised to mobilize the transverse colon.* The splenic flexure was mobilized laparoscopically.* Dissection was then carried down into the pelvis where the peritoneum was incised bilaterally around the rectum making sure to stay medial to the lateral stalks.* The posterior mesorectal dissection was performed all the way down to the levators.* The dissection was then carried bilaterally to release the rectum. with the blunt-tip laparoscopic LigaSure.* The anterior peritoneum was incised and it was bluntly dissected anteriorly.* Once we were able to dissect the rectum as much as the instruments were allowed, then we performed a perineal dissection.

The perineum was prepped and draped in usual sterile fashion.* A Lone Star retractor was used to retract the anus.* The mucosa was incised approximately 5 mm above the dentate line.* A mucosectomy was then performed circumferentially.* The dissection was then performed to join the perineal resection to the abdominal resection.* The mucosectomy and proctectomy specimen were extracted through the anus.* An area identified just proximal to the stump of the inferior mesenteric artery was identified.* This was where the colon was transected using electrocautery.* The mesentery was taken down using a high voltage of electrocautery.* The specimen was passed off to Pathology for further analysis.* We did see a potential scar from where the tumor may have been.* The frozen section revealed that there were no tumor cells within this at the most distal margin.* Given that there were no tumor cells and the pathologist dictated this as greater than 1 cm distal margin.

The coloanal anastomosis was created by using 2-0 Vicryl simple interrupted sutures at 12 locations at the coloanal anastomosis.* At the end of the anastomosis, it was widely patent, confirmed by digital rectal examination.

The abdomen was re-insufflated.* A 19-French Blake drain was placed into the pelvis through the left lower quadrant port and secured with a 2-0 nylon suture.* Approximately, 40 cm from the cecum, terminal ileum was identified for an ileostomy and was oriented with the proximal aspect superiorly.* A 10/12 port was placed through the previously marked ileostomy site.* A ring of skin was excised.* The fascia was incised to accommodate 2 fingers breadth.* The ileum was then pulled up and oriented with the proximal side superior and the inferior side distally.

The laparoscopic ports were pulled under direct visualization of the laparoscope.* The U-stitch was tied down with the PDS at the supraumbilical port site.* The wounds were irrigated with Betadine.* Skin closure was accomplished using 3-0 Vicryl deep dermal buried knot interrupted sutures.* Dermabond was applied.

The distal aspect of the ileostomy was opened using electrocautery.* Vicryl 3-0 sutures were used to tack the distal limb to the dermis level.* Vicryl 3-0 Brooke ileostomy sutures were placed to mature the proximal aspect of the ileostomy.* An ostomy appliance was applied.

At the end of the case; the needle, sponge, and instrument counts were correct.* The left ureteral stent was removed and found to be completely intact.* The patient was converted from lithotomy position to supine position.* An ostomy appliance was applied.* The patient was extubated in the operating room and brought to the PACU with all vital signs stable.* In total, the patient then received 3 liters of crystalloid.* He had 200 cubic centimeters urine output and 15 cubic centimeters estimated blood loss.* The patient tolerated the procedure well without any apparent intraoperative complications.* I was the attending for the case and was present for the entire procedure.