Hello, I need some help on the following OP note. My doc repairs a fistula lap by inflating and then taking the bowel out. The code 44650 is the one I use when it is done open however this was an extremly hard case. Would appreciate any help. I was looking @ 44204, 44238(44650) times 4, 44202 and 44203. Along with the assitant charges.

Operative Reports


Preoperative Diagnosis:

Crohn's disease.

Postoperative Diagnosis:

Fistulizing ileal Crohn's disease.

Procedure(s) Performed:

1. Laparoscopic-assisted right hemicolectomy.
2. Take of multiple ileal fistulas.
3. Takedown of ileocolonic fistula.
4. Repair of small bowel enterotomy at the site of the fistula x
5. Repair of colotomy at the site of the fistula x 1.
6. Small bowel resection x 2.

Teaching Surgeon:

Assistants:___________________M.D. (Dr.____________ assisted with
this operation because there was not a surgical resident
qualified to assist me with this operation).

Specimens: Right colon containing 2 segments of small bowel
from the fistulas.

Estimated Blood Loss: 300 mL.

Indications for Surgery: The patient is a 17-year-old male with
known Crohn's disease. Dr. __________ performed a colonoscopy last
fall and was found to have colonic and ileocolic Crohn's. With
aggressive medical therapy, the colon disease has improved, but
on recent endoscopy, the patient had a tight stricture in the
right colon. His symptoms are consistent with this and he has
right lower quadrant pain and obstructive symptoms. CAT scan
confirmed the same. I have recommended surgery.

Operative Findings: None dictated.

Procedure: The patient was identified in the holding area and
brought back to the operating room where a timeout was performed.
Next, he was administered general anesthesia. A Foley catheter
was placed. His abdomen was prepped and draped in the usual
sterile fashion. After confirming the patient had received
perioperative antibiotics, heparin and stress dose steroids, we
began the procedure. We made an infraumbilical 10 mm incision.
The umbilical stalk was grasped and elevated into the wound. The
rectus fascia was opened sharply into the abdominal cavity. 0
Vicryl stay sutures were used to secure the Hasson port in the
anterior abdominal wall. Pneumoperitoneum was established.
Through the camera we surveyed the abdominal cavity. There was a
clear ileocolic phlegmon in the right lower quadrant. The
remainder of the abdominal cavity appeared normal. Under direct
vision, two left-sided 5 mm ports were placed. In Trendelenburg
in a right side up position, we reflected the small bowel from
the pelvis into the upper abdomen. We then freed the terminal
ileum from the right pelvic inlet sharply. The right ureter was
identified and preserved. The cecum was adherent to the anterior
abdominal wall and this was taken down sharply. We then worked
from lateral to medial, taking the cecum and the right colon away
from the lateral sidewall up towards the hepatic flexure. Once
the got more proximal that the cecum, we encountered normal
tissue planes and mobilization was easier. It became apparent
that this ileocolic phlegmon also involved multiple other loops
of small bowel and the proximal transverse colon. It was clear
that there were multiple fistulas, and to deal with this
appropriately, we had to fully mobilize the hepatic flexure. The
omentum was taken off the transverse colon along its length
towards the splenic flexure. This nicely pediclized the
transverse mesocolon and gave us good exposure to the hepatic
flexure. Attachments were taken down with electrocautery. The
right colic artery was divided with a LigaSure device. The right
colon was mobilized in the midline. I then thought we had enough
to exteriorize the phlegmon and decipher the multiple apparent
fistulas and figure out how to best manage them. Before doing
so, I identified the ligament of Treitz and ran the small bowel
from proximal to distal all the way to the phlegmon. The areas
where there was a small bowel to small bowel fistula was in the
mid small bowel and in the distal small bowel, but not involving
the terminal ileum. A locking grasper was placed on the cecum
and then we enlarged the periumbilical port site to about 4 cm.
A wound protector was placed and the specimen was exteriorized.
We first turned our attention to the fistula between the
phlegmon. It was apparent that multiple small loops were drawn
into the cecum, which was part of the inflammation. The small
bowel loops that were drawn in were in the ileum and in the mid
small bowel, but the terminal ileum was not involved.
Additionally, the proximal transverse colon was drawn in. These
all appeared to be drawn in as innocent bystander type events,
as none of these other loops of bowel appeared to be thickened or
involved primarily by Crohn's disease. We initially began by
taking down the fistula to the transverse colon. This left a
small defect in the transverse colon, which was treated with
multiple interrupted 3-0 Vicryl sutures. We then turned our
attention to the multiple small bowel fistulas. There were three
in total. One was disconnected which left a small defect in the
small bowel, which was closed again with simple suture closure.
The other two areas were more broadly involved and required
actual resection to free them from the phlegmon. To do this, a
GIA-75 stapler was fired proximally and distally to involved
segment and the mesentery was taken between clamps and ligated
with 2-0 Vicryl ties, leaving the involved segment of small bowel
adherent to the mass. This was removed en bloc. Another
similarly involved small bowel segment was resected as well. We
then divided the bowel and the terminal ileum and then at the
proximal transverse colon with the GIA-75 stapler. The ileocolic
mesentery was then divided between clamps and ligated with a
combination of 2-0 Vicryl ties and stick ligatures. The specimen
was passed off the table. This left us with three pieces of
bowel that required restoration of continuity, the ileocolic
anastomosis and two small bowel anastomoses. The two small bowel
anastomoses were created using the GIA stapler as the common
channel. The defect was closed with a TX-60 stapler. I then
returned this down to the abdominal cavity and thoroughly
irrigated the abdominal cavity. I again ran the small bowel from
distal to proximal, and then confirmed the location of the
anastomosis, namely in the ileum and in the mid small bowel. The
terminal ileum was not involved. We then restored ileocolonic
continuity by forming a neoterminal ileum to transverse colon
anastomosis again using a GIA-75 stapler as a common channel.
This defect was closed with a firing of TX 60 stapler. The
mesenteric defect was closed with running 3-0 Vicryl suture. The
omentum was brought back over the bowel. We then closed the
midline fascia with running #1 PDS suture. Subcutaneous tissues
were irrigated and the skin was closed with 4-0 Monocryl, as were
the other port sites. All wounds were sealed with Dermabond.
The patient was extubated and taken to recovery in stable

Teaching Surgeon Attestation: None dictated.
___________________________ MD
Attending,Department of Surgery
dd: 03/29/10 18:29 dt: 03/29/10 19:43