Arrgh. Going back and forth on how this should be coded. Input would be appreciated....
An incision was made in the upper abdomen approaching the xiphoid process to below the level of the umbilicus. The abdominal cavity was entered. Initially exsanguinous fluid was appreciated. The bowel was significantly distended. The liver was unremarkable. There appeared to be some hemorrhage into the lesser sac with blood noted behind the lesser omentum. With further exploration it became clear that the colon was abnormal and there was felt to be a napkin ring lesion at the level of the splenic flexure. As the exploration continued and some mobilization of the spleen progressed, pockets of purulent material were noted. Cultures have been taken. The working diagnosis at that time was that the patient had a lesion of the splenic flexure with rupture into the spleen and abscess. A segmental resection of the splenic flexure was performed. The omentum was mobilized off of the distal transverse colon approaching the splenic flexure. The distal transverse colon was then divided utilizing the GIA stapling device. The proximal left colon was mobilized from the line of Toldt utilizing the Harmonic scalpel. This segment of bowel was divided as well to allow better mobilization of the adherent section at the splenic flexure. With this completed the short gastric vessels were taken down using primarily the Harmonic scalpel with suture ligatures of 2-0 silk utilized as well. Ultimately we were able to mobilize the spleen which was significantly enlarged but largely necrotic from the diaphragm and its' posterior attachments. The pancreas was markedly indurated as it approached the hilum of the spleen and could not be well-dissected from this area. The decision was to resect the distal pancreas utilizing the TA60 with green staples. Good hemostasis was achieved. The adherent splenic capsule was then further mobilized. The residual mesentery of the splenic flexure of the colon was taken down utilizing the Harmonic scalpel. Ultimately with this circumferentially freed, the splenic flexure and spleen were able to be passed of in block dissection. Hemostasis was assured. The abdomen was thoroughly irrigated with antibiotic solution. A 10 millimeter Jackson-Pratt drain was placed. I was unable to reinforce the stump of the pancreas with sutures. However, it was covered with viable tissue which was secured with 3-0 Vicryl suture. The distal suture line in the colon was marked with 2-0 Prolene suture. The more proximal end was prepared for colostomy. The 10 millimeter Jackson-Pratt drain was then placed into the splenic bed. The midline incision was closed with running double-stranded #1 PDS but the distal and mid transverse colon was brought out as a colostomy in the mid left abdomen. It was secured to the fascia with interrupted 3-0 silk suture. Once the midline wound was closed and covered, the colostomy was matured with interrupted 3-0 Vicryl suture. Colostomy bag was applied...
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