EngageMed2
Contributor
Can someone please help with this, this was a complex case and I want to make sure I am coding it correctly.
Exploratory laparotomy
Segmental resection of the sigmoid and part of the left colon and rectum below the peritoneal reflection with mobilization of the splenic flexure
Segmental resection of the small bowel
Central venous line
The patient was taken to the operating room and administered general endotracheal anesthesia. A left subclavian central venous line was started with a single pass of the needle in a sterile field. Using a Seldinger technique a central line was placed. All 3 ports were noted to flush and aspirate without difficulty. The line was sutured in place.
Fiducial stents were placed by the urologic service the details of which will be described in their note
The abdomen and perineum were prepped and draped in a sterile fashion
The abdomen was entered through a midline incision above the umbilicus which was extended down to the pubis. Upon entering the abdomen the patient was noted to have distended bowel mostly colon which was thickened. The Bookwalter was brought in for retraction. She was noted to have an inflammatory versus malignant phlegmon in the sigmoid colon over the vessels. The operation was begun by removing this adherent piece of small bowel resulting in a small enterotomy which was immediately oversewn and tagged.
Later in the operation a short segment of the psyllium was simply excised using a Endo GIA stapler due to the risk of malignancy and then an anastomosis was constructed in a side-to-side fashion using a 60 mm Endo GIA stapler. The resulting enterotomy was closed with a running 3-0 PDS and oversewn with interrupted 3-0 silk Lembert stitches. The defect in the mesentery was closed with interrupted 3-0 silk.
Removal of the inflammatory mass began on the right side of the abdomen opening the retroperitoneum. The right tube and ovary was adherent in the IP ligament was taken down and suture-ligated. This allowed opening of the retroperitoneum and dissection along the right side the mesentery of the sigmoid colon allowed for some mobilization of the upper rectum and also development of a plane between the bladder and the uterus.
Dr. Halter assisted with a complex retroperitoneal dissection on the left side. This was a slow arduous process with over 1 hour spent trying to identify the ureter with a stent this fibrotic mesentery was ultimately freed by mobilizing the left colon as well as the rectum on the left pelvic sidewall and working from each in until it was completely mobilized. The IP ligament was likewise divided as the tube and ovary was densely adherent to the mass. Allowing entry into the retroperitoneum at that point the proximal colon was divided with a GIA stapler. The retrorectal plane was entered and the dissection was carried down in the mesorectal plane to below the area of fibrosis. The dissection was taken anteriorly at the peritoneal reflection anterior to the uterus allowing for this to be mobilized. The retrorectal dissection was performed using the LigaSure. Once the lesion was freed the bowel was divided distally and the rest of the mesentery was taken using the LigaSure and then it was handed off the field.
I have 44120 for the SB resection and 36556 for CVL, what I am debating is the colon/rectal resection with colostomy. I'm thinking LACR 44146 doesnt cover the rectal resection and it included anastomosis which was not done.
Any help is appreciated.
The broad ligament had been taken down to just above the cervix. Dr. Cardenas entered the room and recommended a supracervical hysterectomy the details of which we described in his case. Simply required taking the uterine pedicle with a clamp dividing the supracervical uterus and oversewn this with Dexon
The rectal stump, somewhat thickened, had some separation of the staple line and this was oversewn with interrupted Dexon.
In an effort to construct a tension-free colostomy the splenic flexure was taken down by mobilization of the rest of the left colon taking down the splenic flexure using the LigaSure and the Bovie electrocautery. The abdomen was thoroughly and copiously irrigated including using Irrisept. 3 drains were placed into the abdomen. One on the right side of the abdomen and the right paracolic gutter extending into the pelvis, a right lower quadrant pelvic drain and a left lower quadrant pelvic drain for the left paracolic gutter and into the pelvis.
The bowel was laid out along its mesentery. Site on the anterior abdominal wall was chosen for the colostomy. Skin and subcutaneous tissue was removed. A cruciate incision was made on the lateral border of the rectus sheath and the bowel was eviscerated. After an accurate sponge and needle count the abdomen was closed with interrupted #1 Dexon from each and meeting and tying in the middle. Subcutaneous tissue was thoroughly irrigated and irrigated with Irrisept and then packed and occluded. Some the skin around the umbilicus was approximated with 4 staples.
The ostomy was then matured in a standard fashion with interrupted 4-0 Dexon. The NG tube was then noted to be in good position. Patient did well throughout this procedure. She did receive 2 units of blood 2 of FFP, some calcium and about 2-1/2 L of fluid. She was hemodynamically stable throughout this procedure. She was extubated and returned to the recovery room after having tolerated procedure well. Sponge and instruments were accounted for
Exploratory laparotomy
Segmental resection of the sigmoid and part of the left colon and rectum below the peritoneal reflection with mobilization of the splenic flexure
Segmental resection of the small bowel
Central venous line
The patient was taken to the operating room and administered general endotracheal anesthesia. A left subclavian central venous line was started with a single pass of the needle in a sterile field. Using a Seldinger technique a central line was placed. All 3 ports were noted to flush and aspirate without difficulty. The line was sutured in place.
Fiducial stents were placed by the urologic service the details of which will be described in their note
The abdomen and perineum were prepped and draped in a sterile fashion
The abdomen was entered through a midline incision above the umbilicus which was extended down to the pubis. Upon entering the abdomen the patient was noted to have distended bowel mostly colon which was thickened. The Bookwalter was brought in for retraction. She was noted to have an inflammatory versus malignant phlegmon in the sigmoid colon over the vessels. The operation was begun by removing this adherent piece of small bowel resulting in a small enterotomy which was immediately oversewn and tagged.
Later in the operation a short segment of the psyllium was simply excised using a Endo GIA stapler due to the risk of malignancy and then an anastomosis was constructed in a side-to-side fashion using a 60 mm Endo GIA stapler. The resulting enterotomy was closed with a running 3-0 PDS and oversewn with interrupted 3-0 silk Lembert stitches. The defect in the mesentery was closed with interrupted 3-0 silk.
Removal of the inflammatory mass began on the right side of the abdomen opening the retroperitoneum. The right tube and ovary was adherent in the IP ligament was taken down and suture-ligated. This allowed opening of the retroperitoneum and dissection along the right side the mesentery of the sigmoid colon allowed for some mobilization of the upper rectum and also development of a plane between the bladder and the uterus.
Dr. Halter assisted with a complex retroperitoneal dissection on the left side. This was a slow arduous process with over 1 hour spent trying to identify the ureter with a stent this fibrotic mesentery was ultimately freed by mobilizing the left colon as well as the rectum on the left pelvic sidewall and working from each in until it was completely mobilized. The IP ligament was likewise divided as the tube and ovary was densely adherent to the mass. Allowing entry into the retroperitoneum at that point the proximal colon was divided with a GIA stapler. The retrorectal plane was entered and the dissection was carried down in the mesorectal plane to below the area of fibrosis. The dissection was taken anteriorly at the peritoneal reflection anterior to the uterus allowing for this to be mobilized. The retrorectal dissection was performed using the LigaSure. Once the lesion was freed the bowel was divided distally and the rest of the mesentery was taken using the LigaSure and then it was handed off the field.
I have 44120 for the SB resection and 36556 for CVL, what I am debating is the colon/rectal resection with colostomy. I'm thinking LACR 44146 doesnt cover the rectal resection and it included anastomosis which was not done.
Any help is appreciated.
The broad ligament had been taken down to just above the cervix. Dr. Cardenas entered the room and recommended a supracervical hysterectomy the details of which we described in his case. Simply required taking the uterine pedicle with a clamp dividing the supracervical uterus and oversewn this with Dexon
The rectal stump, somewhat thickened, had some separation of the staple line and this was oversewn with interrupted Dexon.
In an effort to construct a tension-free colostomy the splenic flexure was taken down by mobilization of the rest of the left colon taking down the splenic flexure using the LigaSure and the Bovie electrocautery. The abdomen was thoroughly and copiously irrigated including using Irrisept. 3 drains were placed into the abdomen. One on the right side of the abdomen and the right paracolic gutter extending into the pelvis, a right lower quadrant pelvic drain and a left lower quadrant pelvic drain for the left paracolic gutter and into the pelvis.
The bowel was laid out along its mesentery. Site on the anterior abdominal wall was chosen for the colostomy. Skin and subcutaneous tissue was removed. A cruciate incision was made on the lateral border of the rectus sheath and the bowel was eviscerated. After an accurate sponge and needle count the abdomen was closed with interrupted #1 Dexon from each and meeting and tying in the middle. Subcutaneous tissue was thoroughly irrigated and irrigated with Irrisept and then packed and occluded. Some the skin around the umbilicus was approximated with 4 staples.
The ostomy was then matured in a standard fashion with interrupted 4-0 Dexon. The NG tube was then noted to be in good position. Patient did well throughout this procedure. She did receive 2 units of blood 2 of FFP, some calcium and about 2-1/2 L of fluid. She was hemodynamically stable throughout this procedure. She was extubated and returned to the recovery room after having tolerated procedure well. Sponge and instruments were accounted for