Need Help with Procedure

AmandaM.318414

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Hi,

I would like to know what others are doing with procedures like this one. Anytime we convert from Laparoscopic/robotic to open, I use an open code. I apologize for the length of the note. Thank you in advance for any assistance.

CPT 44640 -- Open closure of intestinal cutaneous fistula

CPT 44160 -- Open right Hemicolectomy


POSTOPERATIVE DIAGNOSIS:
Colocutaneous/enterocutaneous fistula.

NAME OF OPERATION:
1. Robotic-assisted right hemicolectomy.
2. Cystourethroscopy with ureteral stent placement which will be dictated by Urology.


ANESTHESIA:
General.

BRIEF HISTORY:
decision was made to proceed for a right hemicolectomy to rule out malignancy and to control the colocutaneous fistula. Risks and benefits of the procedure were discussed with him including bleeding, infection, possibility of leak, and informed consent was obtained.

DESCRIPTION OF PROCEDURE:
The patient was then placed in lithotomy for the cystourethroscopy to place a right ureteral stent as we felt that the right ureter was possibly adherent to this right lower quadrant inflammatory mass. This was performed by Urology and they will dictate a separate note.

After completing the stent placement, the patient was then positioned in Trendelenburg and slightly tilted to the left. The abdomen was then prepped and draped in sterile fashion. Using the 0-degree Optiview trocar, a small incision was made to the left of the paraumbilical area into the midclavicular line, and the peritoneal cavity was accessed atraumatically. The patient had adhesions into the right lower quadrant. Next, we placed an 8 mm port into the epigastric area and a 3rd 8 mm port into the suprapubic area, and a 4th port was placed into the left lower quadrant and a 5th port was placed into the left mid abdomen. The robot was then docked and positioned over the patient in a safe way, confirming not to compress any of the bony prominences. Once we docked the arms, the camera was inserted and the operation began robotically, taking down all the adhesions. There were adhesions of the omentum to the abdominal wall which was carried carefully took down with combination of cautery and scissors. Once we accomplished that, then we noted an inflammatory mass in the right lower quadrant extending into the abdominal wall with the colocutaneous fistula was. It appeared to be that the terminal ileum and the cecum were the source of the fistula. We continued to dissect the ileum from the lateral abdominal wall and continued to dissecting the cecum, also from the lateral abdominal wall, until we were able to visualize the fistula. We turned attention to mobilizing the right colon from the white line of Toldt which we accomplished robotically and also did reflect the omentum and take the omentum off the cecum robotically. Once we finished all these dissection, then we decided to proceed with the open part of the operation secondary to the severe inflammation of the mass at the retroperitoneum in the right lower quadrant. The robot was undocked. All the ports were removed. A lower midline incision was performed with a 10 blade. It was carried through subcutaneous tissue with electrocautery. The fascia was identified and incised. The peritoneal cavity was entered. A Bookwalter retractor was placed. We then carried our dissection of the right colon and cecum which we freed bluntly from the abdominal wall until we were able to take down the fistula. The fistula appeared to be originating from the cecum and possibly also involving the terminal ileum. It was very hard and indurated in that area but I did not palpate any other masses in the colon, did not palpate any masses in the liver or the peritoneal cavity. We then proceeded by the retroperitoneal dissection by freeing the mass over the indurated inflammatory mass from the ureter and the surrounding structure. Once we were able to do this, then we lifted it and continued our mobilization of the colon from lateral to medial until we were able to identify the duodenum and swipe it off the colon. At this point, we identified the ileocolic vessel and then we used a combination of suture ligation and LigaSure to take it down. We identified the right branch of the middle colic. We also suture ligated it and then continued to take the mesentery down to the ileum and the mesentery up toward the transverse colon by mobilizing also the hepatic flexure and taking down the gastrocolic ligament. Once that all was accomplished, then the ileum was divided with a GIA blue load, and the transverse colon was divided with a GIA blue load. The specimen was removed off the field. Hemostasis was achieved adequately during this process. The ureter was palpated deep into the retroperitoneum. After completing that, we then proceeded by doing a side-to-side end-to-end functional anastomosis between the terminal ileum and the transverse colon with a GIA blue load. The common channel was approximated with a TA 60 blue load. The mesenteric defect was approximated with figure-of-eight silk. The omentum was draped over the anastomosis and also down toward the fistula area which was also controlled with the Bovie. A JP drain was placed through the right gutter and exited through the left lower quadrant. After ensuring adequate count, the laps were removed. The fascia was approximated with looped PDS. The skin was stapled. The port site was approximated with Monocryl. The patient tolerated the procedure, extubated, transferred to recovery in stable condition.

SPECIMENS:
Right colon and omentum.
 
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