I am looking for a CPT Code for a Transanal total mesorectal excision with coloanal anastomosis. I found a similiar code 45110 but the approach is not correct. Same with 44147.
The first part of the operation was performing a rectal
exam under anesthesia, which allowed me to determine that I have enough margin
between the proximal edge of the internal sphincter and the tumor itself. For
that reason, the transanal total mesorectal excision approach was decided. The
patient was taken to the operating room, placed in a supine position. Through
sedation anesthesia with no problem, he became intubated. Initially, we
proceeded to prep and drape the patient in sterile fashion and placed him in
lithotomy. First part of operation was rectal exam under anesthesia, which
allowed me to determine that it was feasible for transanal total mesorectal
excision. I placed a pursestring suture with a 2-0 PDS about 2 cm distal from
the tumor and about 1 cm above the proximal edge of the internal sphincter. I
then transected the mucosa in a circumferential fashion full thickness going
all the way down posteriorly to the mesorectum and then reaching avascular
planes in all directions posteriorly, laterally and anteriorly. Then, we
placed the TAMIS port, placed the cap. We have 3 working ports, 1 for the
camera and 2 for the retraction, suctioning/Bovie and then using the hook
cautery and the LigaSure device we performed a 360-degree circumferential
excision including total mesorectal excision posteriorly, separating from the
prostate anteriorly and then taking off the stalk of tissue on the sides. Both
seminal vesicles were visualized. The prostate stayed intact and then we
performed a very adequate dissection, which allowed us then to reach the
abdomen from bottom. When we violated the peritoneum from the bottom we
started getting pneumoperitoneum. At this point, we placed one 12 mm port in
the right upper quadrant and two 5 mm ports, one in the right flank and the
other one in the supraumbilical incision. The patient was placed in
Trendelenburg position and then I finished the dissection of the peritoneal
reflection in order to release the entire specimen. Pretty much 95% of the
dissection was done from the bottom. We separate the sigmoid from the lateral
attachments. We identified both ureters, isolated the superior rectal vessels
that were dissected in a 360-degree fashion and transected with vascular
staplers. Then, I transected the mesentery and proximal to the superior rectal
vessels up to the colon. The entire specimen was visualized and I was able
then to exteriorize it through the anus all the way through. At this point, we
gave IC green and were able then to confirm adequate perfusion and then
transected, not before placing stay sutures on each quadrant 12, 3, 6 and 9 on
my distal stump in order to anastomose it to the anus. There was no immediate
problem. The excess of sigmoid was transected full thickness and then a single
layer handsewn anastomosis, coloanal, was done without any issues. We were
using the Lone Star retractor, which helped a lot in identification of the
mucosa and performed an arterial anastomosis.
The first part of the operation was performing a rectal
exam under anesthesia, which allowed me to determine that I have enough margin
between the proximal edge of the internal sphincter and the tumor itself. For
that reason, the transanal total mesorectal excision approach was decided. The
patient was taken to the operating room, placed in a supine position. Through
sedation anesthesia with no problem, he became intubated. Initially, we
proceeded to prep and drape the patient in sterile fashion and placed him in
lithotomy. First part of operation was rectal exam under anesthesia, which
allowed me to determine that it was feasible for transanal total mesorectal
excision. I placed a pursestring suture with a 2-0 PDS about 2 cm distal from
the tumor and about 1 cm above the proximal edge of the internal sphincter. I
then transected the mucosa in a circumferential fashion full thickness going
all the way down posteriorly to the mesorectum and then reaching avascular
planes in all directions posteriorly, laterally and anteriorly. Then, we
placed the TAMIS port, placed the cap. We have 3 working ports, 1 for the
camera and 2 for the retraction, suctioning/Bovie and then using the hook
cautery and the LigaSure device we performed a 360-degree circumferential
excision including total mesorectal excision posteriorly, separating from the
prostate anteriorly and then taking off the stalk of tissue on the sides. Both
seminal vesicles were visualized. The prostate stayed intact and then we
performed a very adequate dissection, which allowed us then to reach the
abdomen from bottom. When we violated the peritoneum from the bottom we
started getting pneumoperitoneum. At this point, we placed one 12 mm port in
the right upper quadrant and two 5 mm ports, one in the right flank and the
other one in the supraumbilical incision. The patient was placed in
Trendelenburg position and then I finished the dissection of the peritoneal
reflection in order to release the entire specimen. Pretty much 95% of the
dissection was done from the bottom. We separate the sigmoid from the lateral
attachments. We identified both ureters, isolated the superior rectal vessels
that were dissected in a 360-degree fashion and transected with vascular
staplers. Then, I transected the mesentery and proximal to the superior rectal
vessels up to the colon. The entire specimen was visualized and I was able
then to exteriorize it through the anus all the way through. At this point, we
gave IC green and were able then to confirm adequate perfusion and then
transected, not before placing stay sutures on each quadrant 12, 3, 6 and 9 on
my distal stump in order to anastomose it to the anus. There was no immediate
problem. The excess of sigmoid was transected full thickness and then a single
layer handsewn anastomosis, coloanal, was done without any issues. We were
using the Lone Star retractor, which helped a lot in identification of the
mucosa and performed an arterial anastomosis.