We're not sure what to do with this one


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DESCRIPTION OF PROCEDURE: After general endotracheal anesthesia had been
obtained, the staple lines were removed. The patient's abdomen was
prepped and draped in usual fashion. The midline suture was removed and
the peritoneal cavity was entered. The small bowel was distended and was

Exploration in the right lower quadrant ensued and the ileocolic
anastomosis was gently brought up. It was there that old blood and bilious
fluid was seen coming from the enterotomy staple line. The side-to-side
staple line, however, was intact.

The leak was controlled with the Babcock. A Bookwalter retractor was
placed. A section on the ileum proximal to the anastomosis was chosen for
resection and a window in the mesentery was created with blunt dissection.
The ileum was divided with a 75 mm stapler. The ileal mesentery was taken
down between Kelly clamps and ligated with 2-0 silk ties. The right colon
just distal to the anastomosis was divided as well using the stapler. The
ileocolic anastomosis was passed off the field. The staple line was
inspected and was intact. The suture line where the mesentery defect had
been brought together was released as well. The abdominal wall or the
abdominal cavity was irrigated with 5 liters of warm normal saline until

A disk of skin was removed in the right upper quadrant just above the level
of the umbilicus and the intervening subcutaneous fat was a cored out. A
cruciate incision was made in the abdominal wall fascia and the distal
ileum was brought up through this. Anteriorly on the anterior aspect of
the abdominal wall of the peritoneum, the ileum was tacked to the anterior
abdominal wall with interrupted 3-0 Vicryl sutures. The NG tube tip was
located in the gastric antrum. The omentum was draped back over the bowel.
The abdominal wall fascia was closed with a running looped #1 PDS suture.

Turning to the ileum. The ileostomy was created in a Brooke type fashion
with interrupted 3-0 Vicryl sutures. A wound VAC gray sponge was trimmed
to appropriate size and placed in the midline fascia and covered with the
drapes after the ileostomy appliance had been placed on the skin. The
ostomy was placed over the abdomen and the VAC was placed and put to
suction. No leak was noted.

Sponge, needle and instrument counts were correct. The patient tolerated
procedure well, was extubated and taken to the recovery room in
satisfactory condition.

Any suggestions are appreciated. Patient is post Ileocolic resection. Are we making this harder than it should be? We can find codes that are almost there, but not quite.