marciar
New
I am not sure how to code this procedure. The majority of the work was done removing the ruptured appendix. There was just a small portion of the cecum removed. I am thinking the CPT code should be 44960 with a 22 modifier.
Would appreciate any feedback. Thank you.
OP report:
PREOPERATIVE DIAGNOSES:
1. Right lower quadrant pain with localized peritonitis.
2. Acute appendicitis.
POSTOPERATIVE DIAGNOSES:
1. Acute cecitis with ruptured appendicitis.
2. Right lower quadrant pain.
PROCEDURES: Laparoscopic converted to open partial cecectomy including ruptured appendix.
ESTIMATED BLOOD LOSS: 75 mL
INDICATIONS: A 66-year-old white male, who started abdominal pain three days prior on Thursday. The pain progressively progressed. He toughed it out for several days and finally on Sunday came to the Emergency Room when the pain got so severe. A workup in the Emergency Room showed acute appendicitis with fecaliths and with advanced periappendiceal inflammation. I met with the patient prior to surgery, and I recommended a laparoscopic, possible open appendectomy. I discussed the risks of myocardial infarction, pneumonia, deep venous thrombosis, pulmonary emboli, bleeding requiring transfusion, appendiceal staple line leak, pelvic abscess, and abdominal wall myonecrosis were all discussed and consent was obtained.
PROCEDURE DETAILS: The patient was taken to the Operating Room. He was given preoperative IV antibiotics. A surgical timeout occurred, and he was prepped and draped in the supine position. Once he was asleep, you could feel the appendix and a thick inflammatory process in the right lower quadrant. I did make a supraumbilical cut down to the fascia. The fascia was lifted with two Kocher's and opened under direct vision. A finger sweep showed no intestinal insertions and a blunt balloon trocar was placed and the abdomen was insufflated to 15 mmHg of pressure. An infraumbilical 10 mm trocar was placed.
The patient was placed head down and tilted to the left. Once I saw this, what I saw was that the patient had a severe inflammatory mass including the distal part of the cecum below the ileocecal valve. It was being covered by the terminal ileum. Once I moved the terminal ileum, we could see that the appendix had ruptured and was all corkscrewed on itself and being covered by the terminal ileum and fixed to the lateral wall. Once I moved the small intestine, which was helping to contain this, I saw several fecaliths that were removed. It was at that point that I just felt I could not see what was cecum and what was terminal ileum. The appendix was corkscrewed. It had perforated just outside of the base, and I converted to an open procedure at this time as I could not see the anatomy despite continuously just working diligently in the lateral attachments.
We could see the tip of the appendix. It was intact. It was enlarged. I connected my supraumbilical to my infraumbilical incisions around the left side of the umbilicus and just extended it a tiny bit inferiorly. A Bookwalter retractor was placed. We used a single towel, radiolucent, to pack the small bowel in the left upper quadrant and a Richardson was placed. I started with the healthy cecum dividing the white line of Toldt of the ascending colon, cecum and then staying right on the cecum and rotating it medially. I was able to pinch off some of the inflamed material right at the cecum. With some blunt and sharp dissection, staying right on the appendix and the cecum, I was able to rotate the cecum, the inflamed appendix and the terminal ileum medially through the incision. Despite having it right under our direct vision, it was still very difficult to identify what was appendix and cecum. The cecum was inflamed just around the appendix. I continued dissecting away fatty tissue and inflammatory tissue. I was able to easily see where the terminal ileum came into the cecum. There was healthy noninflamed cecum between the terminal ileum and the appendiceal orifice. I elected to do a partial cecectomy by stapling the distal cecum in a transverse fashion with an Endo-GIA 75 stapler and removing all the cecitis and inflamed cecum with the ruptured appendix. The mesoappendix had been taken down with the Harmonic scalpel. This was then all sent together as a specimen, the distal cecum with the cecitis as well as the ruptured appendix. The cecum I stapled across was noninflamed and healthy. I oversewed this with 3-0 silk pop-offs staple line. There was a small serosal tear in the terminal ileum and I did an enterorrhaphy by closing this with four 3-0 silk sutures. There was no enterotomy made. I ran the distal small intestine. We then irrigated with about 4-5 liters of sterile saline of the pelvis and the right lower quadrant. Luckily, the perforation was more just the fecaliths. There was not a large amount of purulent material. It was just really the fecaliths and just a little bit of surrounding minimal fluid that had been contained by the terminal ileum and the right gutter. I again looked at my cecectomy staple line and it was completely closed and healthy. After the generous irrigation, the omentum and everything was placed back in its anatomical position. I removed my one towel packing. My sponge and instrument was correct x2. The fascia was closed with interrupted #1 Vicryl figure-of-eight stitches. I left the skin and subcutaneous open. He is a thin guy and this should heal quickly for him and we will pack this with saline. Prior to leaving the OR, Anesthesia did a TAP block and then he was taken to the Recovery Room in stable condition.
Would appreciate any feedback. Thank you.
OP report:
PREOPERATIVE DIAGNOSES:
1. Right lower quadrant pain with localized peritonitis.
2. Acute appendicitis.
POSTOPERATIVE DIAGNOSES:
1. Acute cecitis with ruptured appendicitis.
2. Right lower quadrant pain.
PROCEDURES: Laparoscopic converted to open partial cecectomy including ruptured appendix.
ESTIMATED BLOOD LOSS: 75 mL
INDICATIONS: A 66-year-old white male, who started abdominal pain three days prior on Thursday. The pain progressively progressed. He toughed it out for several days and finally on Sunday came to the Emergency Room when the pain got so severe. A workup in the Emergency Room showed acute appendicitis with fecaliths and with advanced periappendiceal inflammation. I met with the patient prior to surgery, and I recommended a laparoscopic, possible open appendectomy. I discussed the risks of myocardial infarction, pneumonia, deep venous thrombosis, pulmonary emboli, bleeding requiring transfusion, appendiceal staple line leak, pelvic abscess, and abdominal wall myonecrosis were all discussed and consent was obtained.
PROCEDURE DETAILS: The patient was taken to the Operating Room. He was given preoperative IV antibiotics. A surgical timeout occurred, and he was prepped and draped in the supine position. Once he was asleep, you could feel the appendix and a thick inflammatory process in the right lower quadrant. I did make a supraumbilical cut down to the fascia. The fascia was lifted with two Kocher's and opened under direct vision. A finger sweep showed no intestinal insertions and a blunt balloon trocar was placed and the abdomen was insufflated to 15 mmHg of pressure. An infraumbilical 10 mm trocar was placed.
The patient was placed head down and tilted to the left. Once I saw this, what I saw was that the patient had a severe inflammatory mass including the distal part of the cecum below the ileocecal valve. It was being covered by the terminal ileum. Once I moved the terminal ileum, we could see that the appendix had ruptured and was all corkscrewed on itself and being covered by the terminal ileum and fixed to the lateral wall. Once I moved the small intestine, which was helping to contain this, I saw several fecaliths that were removed. It was at that point that I just felt I could not see what was cecum and what was terminal ileum. The appendix was corkscrewed. It had perforated just outside of the base, and I converted to an open procedure at this time as I could not see the anatomy despite continuously just working diligently in the lateral attachments.
We could see the tip of the appendix. It was intact. It was enlarged. I connected my supraumbilical to my infraumbilical incisions around the left side of the umbilicus and just extended it a tiny bit inferiorly. A Bookwalter retractor was placed. We used a single towel, radiolucent, to pack the small bowel in the left upper quadrant and a Richardson was placed. I started with the healthy cecum dividing the white line of Toldt of the ascending colon, cecum and then staying right on the cecum and rotating it medially. I was able to pinch off some of the inflamed material right at the cecum. With some blunt and sharp dissection, staying right on the appendix and the cecum, I was able to rotate the cecum, the inflamed appendix and the terminal ileum medially through the incision. Despite having it right under our direct vision, it was still very difficult to identify what was appendix and cecum. The cecum was inflamed just around the appendix. I continued dissecting away fatty tissue and inflammatory tissue. I was able to easily see where the terminal ileum came into the cecum. There was healthy noninflamed cecum between the terminal ileum and the appendiceal orifice. I elected to do a partial cecectomy by stapling the distal cecum in a transverse fashion with an Endo-GIA 75 stapler and removing all the cecitis and inflamed cecum with the ruptured appendix. The mesoappendix had been taken down with the Harmonic scalpel. This was then all sent together as a specimen, the distal cecum with the cecitis as well as the ruptured appendix. The cecum I stapled across was noninflamed and healthy. I oversewed this with 3-0 silk pop-offs staple line. There was a small serosal tear in the terminal ileum and I did an enterorrhaphy by closing this with four 3-0 silk sutures. There was no enterotomy made. I ran the distal small intestine. We then irrigated with about 4-5 liters of sterile saline of the pelvis and the right lower quadrant. Luckily, the perforation was more just the fecaliths. There was not a large amount of purulent material. It was just really the fecaliths and just a little bit of surrounding minimal fluid that had been contained by the terminal ileum and the right gutter. I again looked at my cecectomy staple line and it was completely closed and healthy. After the generous irrigation, the omentum and everything was placed back in its anatomical position. I removed my one towel packing. My sponge and instrument was correct x2. The fascia was closed with interrupted #1 Vicryl figure-of-eight stitches. I left the skin and subcutaneous open. He is a thin guy and this should heal quickly for him and we will pack this with saline. Prior to leaving the OR, Anesthesia did a TAP block and then he was taken to the Recovery Room in stable condition.