Subtotal colectomy, repair of parastomal hernia.


Deltona, FL
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Hoping for some advice on coding this one out. I just don't want to miss anything. Thanks for any and all input.

1. Exploratory laparotomy with lysis of adhesions.
2. Subtotal colectomy.
3. Repair of parastomal hernia.
4. Placement of on On-Q pump for postoperative wound care.

The patient was brought to the operating room after attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. Made our incision after tying off the ileostomy site which was a double lumen ileostomy somewhat surprisingly and then what we did, we went ahead and a prepped her and then placed a sterile colostomy bag on the site and then via draped off the entire wound to make sure we had it isolated. Made a midline incision, got into the abdominal cavity and found a great quantity of adhesions. In fact, we spent several hours taking down these adhesions. We made 1 enterotomy which we repaired with some 3-0 Vicryl and 3-0 silk. It was about 3 to 4 mm in diameter, there was not much spillage. Went ahead and took down all the small bowel and like I said we spent hours doing this and this altered surgical field. We then identified the colon in the left lower quadrant, used a contour device to take down the colon right at the rectum. Then using the LigaSure we took down the mesentery staying relatively close to the colostomy, coming around the splenic flexure, across the transverse colon, then back over to the cecum and the ileum. The previous reports that ileostomy had been performed were an error, there was appendix present. We took down the ileostomy right past the loop, we probably had about 2 cm attached to the loop, took that down and handed off the specimen. At this point, we saw that there was a parastomal hernia and we carried out a primary repair of that stomal hernia with interrupted sutures of 2-0 Ethibond. This tightened up the area nicely. It gave us a good egress. We irrigated the abdominal cavity, quite copiously with antibiotic containing irrigation and carefully reordered the small bowel back within the abdominal cavity, actually we pretty much had it within all along. We had preserved the omentum as we came along and so we replaced the omentum over the top of the small bowel. We did have to take some of the omentum. We checked before we closed, we ran the small bowel in its entirety and found that there was no other enterotomies and there was no significant bleeding from the operative field, although there was a great quantity of operative space, all which was dissected back to oozing, all of our dissection as had been done with either cautery or with the LigaSure. Once that was done, we closed, placed a On-Q pump into position, went up to the top of the apex of the incision, made a some simple incision with a 15 mm blade, then tunneled into the preperitoneal space with the tunnelers and then introduced about, I would say 20 cm long on On-Q pump on both sides of the wound, making sure we stayed away from the ileostomy site and then charged it and then perfused it with about 5 mL per side, then closed with double stranded #1 PDS, followed by irrigation, followed by skin staples. The patient tolerated the procedure quite well.