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Takedown ileostomy, loop colostomy, rt hemicolectomy, sigmoid colectomy

hpierce

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Winchester, VA
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Any recommendations on which way to go with coding this? I'm trying to figure out whether 44160, 44145, 44139 is the way to go or whether 44625-22, 44145, and 44139 would be better. Any thoughts? Thanks, Heather, CPC

PREOPERATIVE DIAGNOSIS: Diverticulitis, status post end ileostomy with diverting loop colostomy.
POSTOPERATIVE DIAGNOSIS: Diverticulitis, status post end ileostomy with diverting loop colostomy.
PROCEDURE PERFORMED: Exploratory laparotomy, takedown of ileostomy loop colostomy, right hemicolectomy, sigmoid colectomy, and mobilization of splenic flexure.
FINDINGS: Extensive adhesions, open sigmoid colon, and chronic diverticulitis.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and placed on the operating room table in supine position. After induction of general anesthetic, she was prepped and draped in usual sterile fashion using ChloraPrep. She had been placed in lithotomy. She had had an end ileostomy and a diverting loop colostomy because of extensive diverticular disease with abscess that required small bowel resection and had anastomosis in that setting. It has been quite some time ago, but she did not want to live with ostomy, so decided to proceed to the operating room for takedown of her ostomy. ______ sigmoid colon inflammation had been resolved at this time; however, after induction of anesthetic, I opened her abdomen and she was found to have extensive adhesions. We were able to take all these down and then identified the anatomy that was left. She had the loop colostomy and end ileostomy. She still had extensive diverticular disease in the pelvis. Once we freed up the small bowel going into the pelvis, it was noted that she had basically an opening under sigmoid colon that had been chronically sealed down against small bowel loops. This was a large perforation presumably secondary to diverticular disease. There really were not many surgical options to deal with this other than to resect it. At this point, I elected to perform a sigmoid colectomy. I took down her ileostomy, which was an end ileostomy and her loop colostomy and stapled both of these off. It was very difficult to mobilize the sigmoid colon, but with great difficulty and quite some time we were able to mobilize the sigmoid colon to the rectum and used a contour stapler to divide this. Both the ureters were identified and preserved. Once the contour stapler was used to divide the distal colon essentially down the rectum a 25 EEA stapler was used to perform anastomosis. I had to mobilize the left colon all the way to the splenic flexure in order to allow adequate mobility of the remainder of the left colon down into the pelvis. Once the splenic flexure had been mobilized to the entire left colon, we were able to do the anastomosis without tension with a 25 EEA. ______ with anastomosis and performed a flex-sig to evaluate the anastomosis to make sure it was patent, which it was, no air leak through the anastomosis so it was watertight. At this point, attention returned to the pelvis. She had had the end ileostomy and also a loop colostomy in the transverse colon rather than do two anastomoses in this area I elected to resect the right colon, which was done by mobilizing the white line of Toldt till the colon was completely mobile. It was already transected at the terminal ileum. We transected the transverse colon just past the hepatic flexure and we were able to takedown the colon and its mesentery using a stapling device. Once the colon was taken down and was removed, anastomosis was then performed side-to-side with staple technique. Mesenteric defect was closed. This allowed a good lot of small bowel and colon to overlie this anastomosis with some omentum after oversewing it. At this point, the fascia was closed with running #1 looped PDS suture and the ostomy sites were closed with #1 PDS. Staples were applied to the skin to close it. Dressings were applied. The patient was taken to the recovery room in satisfactory condition.
 
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