sidney01@roadrunner.com
Contributor
how to code. Perineal exploration with closure of prostatic rectal fistula with interposition gracilis flap. My surgeon (urologist) had two co-surgeons. I will put my surgeons op note on here. Originally here are the codes I had: 15734, 46707 & 46288. However, I am really unclear now. So I am calling on my "expert people" to get feedback. I have not been in urology a long time and do very well on the daily procedures, surgeries, etc. But when it comes to co-surgeries, and these more difficult cases. I am very unsure. I appreciate your help!
DATE OF SURGERY: 04/29/2015
SURGEON: Dr A (my surgeon)
PREOPERATIVE DIAGNOSIS:
Prostatic rectal fistula.
POSTOPERATIVE DIAGNOSIS:
Prostatic rectal fistula.
PROCEDURE PERFORMED:
Perineal exploration with closure of prostatic rectal fistula with
interposition gracilis flap.
CO-SURGEONS:
Dr. B and Dr. C. Dr. A and Dr. B did the perineal
dissection and closure of the rectal and prostatic holes. Dr. A
did a cystoscopy and cannulation of the fistula. Dr. C did the
gracilis flap closure and the interposition attachment.
DESCRIPTION OF PROCEDURE:
After informed consent, Mr. ____________ was taken to the operating room.
General endotracheal anesthesia was provided. His legs were shaved.
His lower abdomen shaved. His perineum was shaved. He was placed in
the high lithotomy position with supports of a 6 inch roll. All
pressure points were well padded. He was then placed in a steep
Trendelenburg. At this point, he was prepped for a cysto. A flexible
cystoscope was negotiated atraumatically under direct vision. The
previously noted fistulous tract was identified within the prostatic
urethra. I then intubated this with a wire and threaded into the
rectum. At this point, I put a finger in the rectum and grasp the wire
and pulled it to the outside where it was clamped. Over this wire, a
Pollock was passed so that we had through and through access with the
Pollock. At this point, the Pollock was clamped to itself after the
wire was removed. The patient was then re-prepped with Hibiclens and
ChloraPrep. He was then sterilely draped. The legs were prepped into
the field. Bilateral for anticipation of the gracilis flap harvest.
This patient had undergone a 2-day bowel prep. A curvilinear incision
was made in the perineum from the ischial spine to the ischial spine,
going across the midline at the level of the perineal body. The skin
and subcutaneous tissues were incised. I dissected through the
transversalis muscle into the space separating the rectum and the
prostate. I was then able to continue dissection sharply and bluntly up
until the area of the fistula was identified. At this point, the
fistula, including the Pollock, was encircled with a vessel loop. At
this point, we dissected the fistulous tracts so that we had free
margins circumferentially for a tension-free closure. At this point,
the Pollock was cut, exposing the rectal fistula. Dr. B closed this
with a running 2-0 PDS suture. I then closed the prostatic portion
primarily with a different 2-0 PDS suture. The catheter was irrigated.
There was no bladder injury. There was no other rectal injury
identified. At this point, Dr. C entered into the room for the
gracilis muscle harvest. See his operative report for details. When
finished, and with assurance that the distal flap was fully
vascularized, I assisted Dr. C in finding a point of attachment
that was proximal to the fistula. The gracilis flap was attached to the
Denonvilliers' fascia in the proximal portion of the prostate, just
between the inner seminal vesicles. At this point, Dr. C and
his resident placed a JP under my direction in the perineum. He then
closed the leg wound. See his operative report for all details. The
patient did tolerate the procedure well. There were no immediate
complications.
DATE OF SURGERY: 04/29/2015
SURGEON: Dr A (my surgeon)
PREOPERATIVE DIAGNOSIS:
Prostatic rectal fistula.
POSTOPERATIVE DIAGNOSIS:
Prostatic rectal fistula.
PROCEDURE PERFORMED:
Perineal exploration with closure of prostatic rectal fistula with
interposition gracilis flap.
CO-SURGEONS:
Dr. B and Dr. C. Dr. A and Dr. B did the perineal
dissection and closure of the rectal and prostatic holes. Dr. A
did a cystoscopy and cannulation of the fistula. Dr. C did the
gracilis flap closure and the interposition attachment.
DESCRIPTION OF PROCEDURE:
After informed consent, Mr. ____________ was taken to the operating room.
General endotracheal anesthesia was provided. His legs were shaved.
His lower abdomen shaved. His perineum was shaved. He was placed in
the high lithotomy position with supports of a 6 inch roll. All
pressure points were well padded. He was then placed in a steep
Trendelenburg. At this point, he was prepped for a cysto. A flexible
cystoscope was negotiated atraumatically under direct vision. The
previously noted fistulous tract was identified within the prostatic
urethra. I then intubated this with a wire and threaded into the
rectum. At this point, I put a finger in the rectum and grasp the wire
and pulled it to the outside where it was clamped. Over this wire, a
Pollock was passed so that we had through and through access with the
Pollock. At this point, the Pollock was clamped to itself after the
wire was removed. The patient was then re-prepped with Hibiclens and
ChloraPrep. He was then sterilely draped. The legs were prepped into
the field. Bilateral for anticipation of the gracilis flap harvest.
This patient had undergone a 2-day bowel prep. A curvilinear incision
was made in the perineum from the ischial spine to the ischial spine,
going across the midline at the level of the perineal body. The skin
and subcutaneous tissues were incised. I dissected through the
transversalis muscle into the space separating the rectum and the
prostate. I was then able to continue dissection sharply and bluntly up
until the area of the fistula was identified. At this point, the
fistula, including the Pollock, was encircled with a vessel loop. At
this point, we dissected the fistulous tracts so that we had free
margins circumferentially for a tension-free closure. At this point,
the Pollock was cut, exposing the rectal fistula. Dr. B closed this
with a running 2-0 PDS suture. I then closed the prostatic portion
primarily with a different 2-0 PDS suture. The catheter was irrigated.
There was no bladder injury. There was no other rectal injury
identified. At this point, Dr. C entered into the room for the
gracilis muscle harvest. See his operative report for details. When
finished, and with assurance that the distal flap was fully
vascularized, I assisted Dr. C in finding a point of attachment
that was proximal to the fistula. The gracilis flap was attached to the
Denonvilliers' fascia in the proximal portion of the prostate, just
between the inner seminal vesicles. At this point, Dr. C and
his resident placed a JP under my direction in the perineum. He then
closed the leg wound. See his operative report for all details. The
patient did tolerate the procedure well. There were no immediate
complications.
