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Question Repair of high imperforate anus with bladder fistula, combined laparoscopic (abdominal) and sacral approach

amanda19791

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Could someone help me with a code? The code that is used by my provider is 46742 but I could not find a code for the lap. See Op note. Also procedure was performed by two surgeons.

OP note #1:
Recto-bladder neck fistula identified, divided, and repaired laparoscopically.
Mobilization of the recto-sigmoid performed for the adequate length for the pull-through with posterior sagittal anorectoplasty.

I assisted in this procedure due to the unavailability of a qualified resident. I assisted with the laparoscopic portions and posterior sagittal anorectoplasty. This noticed a detail my involvement. For further details, please see Dr. C's operative note.
After Dr. C gained entry into the abdominal cavity, the rectum was identified and followed distally. A combination of blunt dissection along with electrocautery was utilized to incise the peritoneum away from the rectum. Bilateral dissection was carried out dividing the lateral attachments of the rectum and controlling the blood supply with cautery. The rectum was freed posteriorly. Caudal dissection eventually revealed the rectal bladder neck fistula. The vas deferens were identified and protected. The ureters were seen, particularly the left ureter with noted hydroureter. The rectal bladder neck fistula was divided and the bladder closed with 2 sequential PDS Endoloops.

The patient was turned and placed in a prone jackknife position. A neuromuscular stimulator was utilized to identify the sphincter muscle complex which was marked. Posterior sagittal dissection was performed from the coccyx to anterior to the muscle complex. Staying directly in the midline and separating the muscle complex in the midline. The dissection was carried in a cephalad manner until entry was gained into the peritoneal cavity. The Foley catheter was able to be palpated anterior to the dissection preventing injury to the urinary structures. After gaining entry into the peritoneal cavity, the distal rectum was not immediately apparent. A 12 mm trocar was placed through the posterior sagittal dissection into the peritoneum, however we are unable to sufficiently insufflated and identified the distal rectum. The patient was turned into a supine position. The abdomen was again insufflated. The colon was identified and further mobilization performed by dividing the mesentery away from the wall of the rectum to preserve the marginal blood supply. After adequate mobilization, a hemostat was placed through the posterior sagittal incision into the peritoneum and utilized to grasp the distal rectum and pull it through the perineal dissection. The orientation of the rectum was carefully noted so as to avoid twisting of the bowel. The orientation was noted for repositioning of the patient. The patient was repositioned in the prone jackknife position after closure of the trocar sites.


Op Note#2:

Large fistula to the bladder neck.

Description of Procedure:
Indication: The patient was noted at birth to have imperforate anus as well as GU anomalies. He has a high lesion, so diverting ostomy was performed with plans for repair at 6 months. However, he has had multiple severe urinary tract infections, so division of the fistula is indicated early. He is taken to the operating room on a semi-elective basis for PSARP while leaving his diverting ostomy following a discussion with the parents regarding the procedure and its attendant risks including, but not limited to injury to intra-abdominal or pelvic organs, stricture or stenosis, bleeding and infection. Additionally, the potential for long-term difficulties with constipation or incontinence were discussed. They demonstrated good understanding and desired to proceed.

Procedure: The patient was placed in the supine position. Adequate anesthesia was initiated. A urinary catheter was placed. The current colostomy and mucous fistula were each oversewn with 3-0 silk figure-of-eight sutures. Antibiotics were administered. A full lower-body prep and drape were performed in a sterile fashion. A bio-occlusive dressing was placed over the stomas. A small umbilical incision was made. Through this, a 5mm Step trocar was inserted. Pneumoperitoneum was established with carbon dioxide to 15mmHg, which was well tolerated. Three other 5mm trocars were placed under laparoscopic guidance in the right upper, mid and lower abdomen. The sigmoid rectum was identified. The left ureter and bilateral vas deferens were also identified. Dissection of the rectum was performed by dividing its mesentery as needed from the pelvic brim to the fistula. Once the fistulous connection toi the base of the bladder was clearly identified, it was divided as close as reasonable to the bladder and closed with two Endoloops. Pneumoperitoneum was released and the trocars were removed. The position was changed to prone jack-knife with Trendelenburg. The center of the anal wink was identified with stimulation. The gluteal cleft was incised from the coccyx to the perineal body. This was brought down through the subcutaneous tissues, fascia and muscle of the levator complex in the midline until entering the peritoneal cavity. Attempts were made to deliver the colonic portion of the divided fistula but there were unsuccessful. Therefore, the position was changed to supine and pneumoperitoneum was re-established. The sigmoid colon was further mobilized. A hemostat placed through the perineal wound was able to grasp the distal colon and bring it through the pelvis and out, maintaining orientation. Pneumoperitoneum was again released. The fascia of each trocar site was closed at this time with 4-0 PDS sutures. The position was changed back to prone jack-knife. The perineal body was reconstructed with interrupted 5-0 Vicryl sutures. The muscle complex was re-approximated over the rectum with interrupted 5-0 Vicryl sutures, ensuring that the rectum was not compromised. The final 2cm of the rectal limb was amputated. The neoanus was constructed with interrupted full-thickness 5-0 PDS sutures to the squamous edge. The rectum was probed and found to be pateent to a 10mm Hagar dilator. The skin was re-approximated with interrupted subcuticular 5-0 Monocry sutures, both posterior and anterior to the neoanus. The wound was infiltrated with Marcaine. Dermabond was applied. Xeroform gauze was placed in the anus. Once again, the position was changed to supine. Each trocar site was infiltrated with Marcaine. The skin of each site was closed with Dermabond. The sutures closing the stomas were removed and a stoma bag was applied. The procedure was well tolerated and there were no apparent complications.

As the attending surgeon, I was present and scrubbed for the duration of the procedure.
 
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