nlbarnes
Expert
Just need confirmation of this or if there is another code for the colon lavage (44701) please.
44207, 44187, 44213, 44701 - (44701 is what I really need feedback on please).
PROCEDURE:
Laparoscopic coloanal resection with diverting loop ileostomy,
takedown of splenic flexure, and on-table lavage
DESCRIPTION OF PROCEDURE:
The plane between the left kidney and the descending colon mesentery was open with the #5 EnSeal.
The splenic flexure was taken down with a #5 EnSeal taking care to
avoid injury to the spleen. This was a very high splenic flexure and
the bowel was chronically dilated from her chronic obstruction and the
bowel felt heavy. I felt most likely that this bowel was full of
thick stool, so we were extremely careful as always to avoid any
injury to the bowel. The splenic flexure was almost tucked under the
lateral aspect of the spleen, but we finally did manage to get it down
with a #5 EnSeal. We then turned our attention to the base of the
sigmoid colon mesentery. We identified and preserved the right
ureter. We opened the peritoneum over the base of the right hand side
of the sigmoid colon mesentery, entered the presacral space, and then
lifted up the superior rectal artery and entered through the filmy
plane with the left-sided dissection. The left ureter was identified
from the right side and again protected. We identified the base of
the inferior mesenteric artery. In fact, as we were dissecting the
base white line on the aorta surface, there was a what appeared to be
a node. It was a round structure. It was not particularly hard, but
certainly distinct and we dissected that off the surface of the aorta
and sent that separately as high inferior mesenteric artery node. We
then divided the inferior mesenteric artery at its base with a Endo-
GIA 60 white reticulating stapler 2.5 mm. We then reinforced the
staple line as per my habit with large hemoclips. We then turned to
the pelvis. I performed a total mesorectal excision. Eventually, I
placed a hand GelPort through a small Pfannenstiel incision to help
facilitate this dissection. It was made challenging by the size of
the tumor, which nearly filled the pelvis. I did feel that I was able
to dissect in a clean plane around the tumor and at no point did I
feel that I was dissecting into tumor. Anteriorly, the dissection got
more challenging as it was relatively more stuck anteriorly. There
was a flap of tissue that appeared to be left over from her previous
hysterectomy. We opened the peritoneum over this flap and then we
actually peeled this flap down on top of the rectum and eventually
found the vagina behind this flap, and fortunately the plane between
the more distal rectum and the vagina appeared to be filmy and clean.
This conveniently placed a flap of tissue on top of the rectum, which
should make a good anterior margin as the puckered tumor was well
beneath this. The tumor appeared to be somewhat more distal than I
had anticipated in the office and possibly the height from the anal
verge was underestimated by the fact that the patient has fairly large
butt cheeks. I entered the wall there was fascia posteriorly and went
into the anal canal and continued with the #5 EnSeal until I was able
to peel the vagina down. At some point, I put in a same marks through
the hand port and did some dissection with the cautery in this fashion
and then went back and forth between that and the laparoscopic
instrumentation until I got the rectum dissected down distal to the
tumor such that by palpation, I had about a 2 cm margin. I then noted
that her rectum was quite large and thick and rather than take several
fires of the Endo-GIA, I elected to place a green contour stapler
through the hand port and I was able to work this down into the
pelvis, taking care to avoid injury to the vagina and I divided the
rectum distal to the tumor with a Contour green stapler. We then
extruded the specimen and immediately it was obvious that the patient
had a colon that was full of stool and dilated proximal to her near
obstructing rectal cancer. The stool was not hard ball, rather thick
pasty feeling stool. I at this point considered her options. The
rectum was divided so far distally that if I made a colostomy now,
this would certainly be a permanent colostomy. At the same time, if
I made a coloanal anastomosis with this bowel full of so much thick
stool, I was very concerned that she would have a leak. Therefore, I
elected to perform an on-table lavage. In order to do this, I had to
mobilize the cecum laparoscopically, so I could bring it medially up
into the small Pfannenstiel incision, where the hand port was and I
took a 16-French Foley placed it about 5 cm proximal to the cecum in
the terminal ileum on the antimesenteric surface then tied it in place
with a 2-0 silk pursestring suture. I fed it into the cecum and
inflated the balloon, so that I could feel the balloon in the cecum.
This was then hooked to a 4 L Urology type saline irrigation. I then
took a look at the rectal specimen. I did not want to shorten by
length as far as being able to reach the pelvis at that point in this
surgery, so I divided the sigmoid descending junction essentially
opposite the IMA takeoff between Kocher clamps and then suture ligated
the distal side with 2-0 silk suture. I then got corrugated vent
tubing that was sterile and placed it in the proximal side and tied it
in with umbilical tape and then in order to really get it to stay, I
had to use a 0 silk suture for a pursestring that went through the
tubing as well as the bowel, and this got the tubing to stay nicely in
place in the sigmoid descending junction. I then dropped the tubing
into a bucket on the floor and then we performed an on-table lavage,
irrigating all 4 L through the patient's colon. Lot of thick stool
came out. I used my hand to try to milk of the lavage fluid around
the colon and by the end of the lavage, I had light brown watery fluid
only coming through and I could not feel any larger thick stool any
longer in the patient's colon. I then divided the bowel just proximal
to this site with the automatic pursestring device for the pathology
site, so I sewed the site of the on-table lavage back to the oversewn
more distal side. We make the confirmation of this tissue
anatomically just so the specimen would be easier to understand. The
rectosigmoid specimen was taken off the table and then I placed a 28
EEA anvil tying down automatic pursestring, cleaning off the bowel as
per my habit, and then sewing a second 3-0 Prolene pursestring as per
my habit. The bowel did not have bleeding as I cut it, but it did
look viable when I initially cut it. I dropped it back down in the
abdomen. We then took away all the dirty instruments, which were on
towels and took those towels with them and changed our gowns and
gloves. Then I returned to the laparoscopic portion of the case to
assess the reach and check around the abdomen post on-table lavage.
When I went to do this, I discovered that it seemed that the patient
had a skinny edge of the descending colon in a fairly long piece.
Eventually, what I figured it out about this was that I think the
patient had a long loopy descending colon, possibly with some more
sigmoid that in taking the IMA at the base had devascularized that
area enough that I thought the bowel looked dusky and I was not
comfortable using it for anastomosis. Initially, I was very concerned
that I would not be able to get the healthy-appearing bowel at the
more proximal descending colon to reach the pelvis. However, I was
able to visualize the ligament of Treitz and take down attachments
there. I divided the inferior mesenteric vein at its origin between
large hemoclips, two on each side, and continued to take attachments
that were nonvascular at the base of the mesentery to the descending
colon. Once I did this, I should note that I also took the remaining
gastrocolic omentum off the colon down all the way across to the right
hand side and this mobilized the colon, so it fell down toward the
pelvis. Between this combination of moves, I was actually able to
reach the probably mid descending colon all the way down to her anus
without difficulty. I extruded the bowel again, removed the portion
that appeared ischemic, cutting it with the automatic pursestring
device. Mesentery was divided between Mayo clamps and ligated with 2-
0 silk suture and then sent that as additional descending colon to
Pathology. I then placed the same automatic pursestring device, and
this removed the anvil that I had placed previously and replaced in
this new portion of bowel in the exact same fashion and dropped it
back into the abdomen. I changed gowns and gloves again, and then
checked again and now this was now very pink and healthy bowel with
bled at the edges when I was placing the anvil. It dropped nicely all
the way down in the pelvis. I then performed a #28 green 4.8 mm
Covidien EEA anastomosis and both donuts were excellent. We did test
the anastomosis under saline insufflating with the rigid
sigmoidoscope, but I should note that the anastomosis is approximately
2 cm from the dentate line certainly, no more than 4 cm from the
verge. I could just barely get the sigmoidoscope in to achieve a
test. There was no tension on the anastomosis, but certainly there
would not have been enough laxity to make a coloanal J-pouch. Due to
the low level of the anastomosis in that and there would be some on-
table lavage dirty fluid left in the colon, I elected to perform a
diverting loop ileostomy on this patient. I placed a 10 flat Jackson-
Pratt drain deep in the pelvis and sewed it in with 2-0 nylon suture,
placing it through the left mid quadrant port site. I then placed a 5
port through the site marked in the right lower quadrant by the stoma
therapist, made a circular incision in the skin and fat, and excised a
wedge of skin and fat. This patient was moderately obese in this
location. I made a cruciate incision in the fascia and enlarged the
hole to two fingerbreadths and prolapsed out the terminal ileum. I
should note that when I removed the on-table lavage catheter, I closed
the small hole that was about 5 mm in size with interrupted 3-0 silk
sutures initially and then on top of that, interrupted 3-0 silk
Lembert sutures. Care was taken to avoid narrowing the terminal
ileum. I made sure the site of the ileostomy was well enough above
that site that it should not interfere with my ability to close the
ileostomy. I made sure laparoscopically that the distal end was
inferior on the patient. We used a 16-French red rubber catheter for
a stoma rod and sewed that in place with 3-0 Vicryl suture. We re-
insufflated the abdomen and checked all quadrants for bleeding.
Hemostasis appeared excellent. We closed with 0 Vicryl at the 12 port
site and the right lower quadrant with a 0 Vicryl Endo Close. We
removed the hand port and then getting a new closing set. At this
point, we did have clean gloves already we redraped with clean towels
and closed the incision with running 0 Vicryl to the peritoneum and
running #1 PDS to the fascia. We re-insufflated the abdomen, nothing
was caught in the incision. All the remaining ports removed under
direct vision. There was no evidence of bleeding. The skin of all
five ports with the small Pfannenstiel incision was closed with 4-0
Monocryl subcuticular stitch. Dermabond was placed. We then matured
the ileostomy in a modified Brooke fashion, de-emphasizing the distal
end using interrupted 3-0 Vicryl sutures. A stoma bag was placed.
44207, 44187, 44213, 44701 - (44701 is what I really need feedback on please).
PROCEDURE:
Laparoscopic coloanal resection with diverting loop ileostomy,
takedown of splenic flexure, and on-table lavage
DESCRIPTION OF PROCEDURE:
The plane between the left kidney and the descending colon mesentery was open with the #5 EnSeal.
The splenic flexure was taken down with a #5 EnSeal taking care to
avoid injury to the spleen. This was a very high splenic flexure and
the bowel was chronically dilated from her chronic obstruction and the
bowel felt heavy. I felt most likely that this bowel was full of
thick stool, so we were extremely careful as always to avoid any
injury to the bowel. The splenic flexure was almost tucked under the
lateral aspect of the spleen, but we finally did manage to get it down
with a #5 EnSeal. We then turned our attention to the base of the
sigmoid colon mesentery. We identified and preserved the right
ureter. We opened the peritoneum over the base of the right hand side
of the sigmoid colon mesentery, entered the presacral space, and then
lifted up the superior rectal artery and entered through the filmy
plane with the left-sided dissection. The left ureter was identified
from the right side and again protected. We identified the base of
the inferior mesenteric artery. In fact, as we were dissecting the
base white line on the aorta surface, there was a what appeared to be
a node. It was a round structure. It was not particularly hard, but
certainly distinct and we dissected that off the surface of the aorta
and sent that separately as high inferior mesenteric artery node. We
then divided the inferior mesenteric artery at its base with a Endo-
GIA 60 white reticulating stapler 2.5 mm. We then reinforced the
staple line as per my habit with large hemoclips. We then turned to
the pelvis. I performed a total mesorectal excision. Eventually, I
placed a hand GelPort through a small Pfannenstiel incision to help
facilitate this dissection. It was made challenging by the size of
the tumor, which nearly filled the pelvis. I did feel that I was able
to dissect in a clean plane around the tumor and at no point did I
feel that I was dissecting into tumor. Anteriorly, the dissection got
more challenging as it was relatively more stuck anteriorly. There
was a flap of tissue that appeared to be left over from her previous
hysterectomy. We opened the peritoneum over this flap and then we
actually peeled this flap down on top of the rectum and eventually
found the vagina behind this flap, and fortunately the plane between
the more distal rectum and the vagina appeared to be filmy and clean.
This conveniently placed a flap of tissue on top of the rectum, which
should make a good anterior margin as the puckered tumor was well
beneath this. The tumor appeared to be somewhat more distal than I
had anticipated in the office and possibly the height from the anal
verge was underestimated by the fact that the patient has fairly large
butt cheeks. I entered the wall there was fascia posteriorly and went
into the anal canal and continued with the #5 EnSeal until I was able
to peel the vagina down. At some point, I put in a same marks through
the hand port and did some dissection with the cautery in this fashion
and then went back and forth between that and the laparoscopic
instrumentation until I got the rectum dissected down distal to the
tumor such that by palpation, I had about a 2 cm margin. I then noted
that her rectum was quite large and thick and rather than take several
fires of the Endo-GIA, I elected to place a green contour stapler
through the hand port and I was able to work this down into the
pelvis, taking care to avoid injury to the vagina and I divided the
rectum distal to the tumor with a Contour green stapler. We then
extruded the specimen and immediately it was obvious that the patient
had a colon that was full of stool and dilated proximal to her near
obstructing rectal cancer. The stool was not hard ball, rather thick
pasty feeling stool. I at this point considered her options. The
rectum was divided so far distally that if I made a colostomy now,
this would certainly be a permanent colostomy. At the same time, if
I made a coloanal anastomosis with this bowel full of so much thick
stool, I was very concerned that she would have a leak. Therefore, I
elected to perform an on-table lavage. In order to do this, I had to
mobilize the cecum laparoscopically, so I could bring it medially up
into the small Pfannenstiel incision, where the hand port was and I
took a 16-French Foley placed it about 5 cm proximal to the cecum in
the terminal ileum on the antimesenteric surface then tied it in place
with a 2-0 silk pursestring suture. I fed it into the cecum and
inflated the balloon, so that I could feel the balloon in the cecum.
This was then hooked to a 4 L Urology type saline irrigation. I then
took a look at the rectal specimen. I did not want to shorten by
length as far as being able to reach the pelvis at that point in this
surgery, so I divided the sigmoid descending junction essentially
opposite the IMA takeoff between Kocher clamps and then suture ligated
the distal side with 2-0 silk suture. I then got corrugated vent
tubing that was sterile and placed it in the proximal side and tied it
in with umbilical tape and then in order to really get it to stay, I
had to use a 0 silk suture for a pursestring that went through the
tubing as well as the bowel, and this got the tubing to stay nicely in
place in the sigmoid descending junction. I then dropped the tubing
into a bucket on the floor and then we performed an on-table lavage,
irrigating all 4 L through the patient's colon. Lot of thick stool
came out. I used my hand to try to milk of the lavage fluid around
the colon and by the end of the lavage, I had light brown watery fluid
only coming through and I could not feel any larger thick stool any
longer in the patient's colon. I then divided the bowel just proximal
to this site with the automatic pursestring device for the pathology
site, so I sewed the site of the on-table lavage back to the oversewn
more distal side. We make the confirmation of this tissue
anatomically just so the specimen would be easier to understand. The
rectosigmoid specimen was taken off the table and then I placed a 28
EEA anvil tying down automatic pursestring, cleaning off the bowel as
per my habit, and then sewing a second 3-0 Prolene pursestring as per
my habit. The bowel did not have bleeding as I cut it, but it did
look viable when I initially cut it. I dropped it back down in the
abdomen. We then took away all the dirty instruments, which were on
towels and took those towels with them and changed our gowns and
gloves. Then I returned to the laparoscopic portion of the case to
assess the reach and check around the abdomen post on-table lavage.
When I went to do this, I discovered that it seemed that the patient
had a skinny edge of the descending colon in a fairly long piece.
Eventually, what I figured it out about this was that I think the
patient had a long loopy descending colon, possibly with some more
sigmoid that in taking the IMA at the base had devascularized that
area enough that I thought the bowel looked dusky and I was not
comfortable using it for anastomosis. Initially, I was very concerned
that I would not be able to get the healthy-appearing bowel at the
more proximal descending colon to reach the pelvis. However, I was
able to visualize the ligament of Treitz and take down attachments
there. I divided the inferior mesenteric vein at its origin between
large hemoclips, two on each side, and continued to take attachments
that were nonvascular at the base of the mesentery to the descending
colon. Once I did this, I should note that I also took the remaining
gastrocolic omentum off the colon down all the way across to the right
hand side and this mobilized the colon, so it fell down toward the
pelvis. Between this combination of moves, I was actually able to
reach the probably mid descending colon all the way down to her anus
without difficulty. I extruded the bowel again, removed the portion
that appeared ischemic, cutting it with the automatic pursestring
device. Mesentery was divided between Mayo clamps and ligated with 2-
0 silk suture and then sent that as additional descending colon to
Pathology. I then placed the same automatic pursestring device, and
this removed the anvil that I had placed previously and replaced in
this new portion of bowel in the exact same fashion and dropped it
back into the abdomen. I changed gowns and gloves again, and then
checked again and now this was now very pink and healthy bowel with
bled at the edges when I was placing the anvil. It dropped nicely all
the way down in the pelvis. I then performed a #28 green 4.8 mm
Covidien EEA anastomosis and both donuts were excellent. We did test
the anastomosis under saline insufflating with the rigid
sigmoidoscope, but I should note that the anastomosis is approximately
2 cm from the dentate line certainly, no more than 4 cm from the
verge. I could just barely get the sigmoidoscope in to achieve a
test. There was no tension on the anastomosis, but certainly there
would not have been enough laxity to make a coloanal J-pouch. Due to
the low level of the anastomosis in that and there would be some on-
table lavage dirty fluid left in the colon, I elected to perform a
diverting loop ileostomy on this patient. I placed a 10 flat Jackson-
Pratt drain deep in the pelvis and sewed it in with 2-0 nylon suture,
placing it through the left mid quadrant port site. I then placed a 5
port through the site marked in the right lower quadrant by the stoma
therapist, made a circular incision in the skin and fat, and excised a
wedge of skin and fat. This patient was moderately obese in this
location. I made a cruciate incision in the fascia and enlarged the
hole to two fingerbreadths and prolapsed out the terminal ileum. I
should note that when I removed the on-table lavage catheter, I closed
the small hole that was about 5 mm in size with interrupted 3-0 silk
sutures initially and then on top of that, interrupted 3-0 silk
Lembert sutures. Care was taken to avoid narrowing the terminal
ileum. I made sure the site of the ileostomy was well enough above
that site that it should not interfere with my ability to close the
ileostomy. I made sure laparoscopically that the distal end was
inferior on the patient. We used a 16-French red rubber catheter for
a stoma rod and sewed that in place with 3-0 Vicryl suture. We re-
insufflated the abdomen and checked all quadrants for bleeding.
Hemostasis appeared excellent. We closed with 0 Vicryl at the 12 port
site and the right lower quadrant with a 0 Vicryl Endo Close. We
removed the hand port and then getting a new closing set. At this
point, we did have clean gloves already we redraped with clean towels
and closed the incision with running 0 Vicryl to the peritoneum and
running #1 PDS to the fascia. We re-insufflated the abdomen, nothing
was caught in the incision. All the remaining ports removed under
direct vision. There was no evidence of bleeding. The skin of all
five ports with the small Pfannenstiel incision was closed with 4-0
Monocryl subcuticular stitch. Dermabond was placed. We then matured
the ileostomy in a modified Brooke fashion, de-emphasizing the distal
end using interrupted 3-0 Vicryl sutures. A stoma bag was placed.
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