Trying to code for a takedown of a cholecystocolonic fistula

ctawney

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My Doctor did a takedown of a cholecystocolonic fistula, a cholescytectomy and a hepaticduodenostomy. I have all the codes I need except for the takedown of the fistula. If anyone can please help with this it would be greatly appreciated. The OP note is listed below.

Thank You!!


INDICATIONS: The patient is an 80-year-old who had presented to the
hospital several months ago with obstructive jaundice. She had an
endoscopic retrograde cholangiopancreatogram (ERCP) which showed a
stricture in the bile duct, but upon opacification of the duct,
there appeared to be a connection through the gallbladder to the
colon and the patient was stented. She is now brought to the
operating room now for definitive management. The patient was
apprised of the risks, benefits, and rationale of the proposed
procedure. After adequate time for deliberation and questions, she
agreed to proceed.

PROCEDURE: She was brought to the operating room. General
anesthesia was administered. A Foley catheter, nasogastric tube,
and appropriate lines were placed. The abdomen was prepped and
draped in a sterile fashion. A midline incision was made extending
from xiphoid to just below the umbilicus. The linea alba was split.
The peritoneal cavity was entered sharply. Electrocautery was used
to open the incision along its entire length. The falciform
ligament was taken down. The round ligament was tied and held with
a 0 silk. An Omni-type retractor was placed. The abdomen was
explored. We did not see any evidence of cancer or any metastatic
disease.

We began the procedure by taking down colon adhesions to the
abdominal wall and then to the liver. A time-consuming and tedious
dissection ensued as we then defined where the colon was stuck to
the fundus of the gallbladder which was extremely contracted and
thickened. We then were able to isolate this and fired an Endo-GIA
stapler with a 63.5 load across this area. We were then able to
retract the colon out of the way. The gallbladder was then taken
out of the liver bed using electrocautery. This was difficult
because it was thickened and there was no defined plane. We
continued this dissection down inferiorly. We then, in a
time-consuming and tedious dissection, began to define the
structures of the porta hepatis, identifying the hepatic artery, and
then ultimately dissecting out the common bile duct and common
hepatic duct. Unfortunately, the gallbladder seemed to terminate
with the wide mouth on the sidewall of the common bile duct. No
cystic duct was ever identified. A cystic artery was dissected out,
clipped, and divided. Ultimately, the gallbladder was taken off of
the bile duct using sharp dissection and electrocautery. This
specimen was delivered from the operative field. The edges of the
bile duct were débrided. Some of this tissue was sent for biopsy,
although it appeared to be inflammatory and not cancerous. The
stent was viewed and ultimately removed.

At this point, we elected to perform a hepaticoduodenostomy leaving
the bile duct intact, but anastomosing to this wide sidewall defect.
An enterotomy was made longitudinally on the duodenum and a suture
was placed of 4-0 Polysorb in the mid-wall and this was anastomosed
to the most distal apex of the bile duct defect and a time-consuming
and tedious process then ensued as we placed 4-0 Polysorb sutures
through-and-through the small bowel and through-and-through the bile
duct to complete an anastomosis. Prior to final sutures we checked
for patency with Bakes dilators and it was noted to be patent. When
this was completed, a 10 Jackson-Pratt drain was placed through a
separate stab incision into Morison pouch. We irrigated and
suctioned. When we were satisfied, the abdomen was closed with #1
Prolene beginning proximally and distally, and securing this to the
middle of the incision. The subcutaneous tissue was irrigated. The
skin was coapted with staples. Dressings were applied. The patient
tolerated the procedure well. The drain was secured with 3-0 nylon.
All instrument counts, needle counts, and sponge counts were
correct at the time of closure.

POSTOPERATIVE DIAGNOSIS: Cholecystenteric fistula with biliary
obstruction.
 
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