I don't come across these to often.
Is this the right selection coding
CPT 44120- Enterectomy, resection of small intestine; single resection and anastomosis
CPT 44310 - Ileostomy or jejunostomy, non-tube
Extensive lysis of adhesions
Small Bowel resctio nwith reanastomosis
Jejunostomy feeing tupe placement.
Description of report
Midline incision was incised and, using electocaturery entered into the abdominal space. Along the xiphoid there were some new calcium deposits within soft tissue. These were resected, and with a rib cutter, removed to trim off the xiphoid. There were dense adhsions. One pocket we entered into was not intraluminal in the bowel but felt like maybe an old fat necrosis or old walled-off infection pocket. We continue with extensive lysis of adhesions and were able to free up the entire small bowel with delicate dissection with scissors and short bursts of electrocatuery. We were able to dissect the entire segment of the small bowel all the way first on the side of the abdomen, followed by the right side. ONce we had attained all this, we identified the terminal ilieum and ligament of Treitz and upon doing so about 30cm distal to this where it appeared where it might have been where I had the previous J tube back in june of 2009, an area of either leak or necrosis, but the small bowel was cetainly knuckled, and there was certainly risk of concern for cancer. Once we freed this up, we decided to perform a small bowel segmental resection and then reanastomosis.
With electrocautery we scored the mesentery and then , using clamps, clamped both sides of the mesentery and cut multiple times in succession. We were able to do this and tie the mesentery with 2-0 silk. Once we were all done with all the different parts of the mesentery, the bowel was divided with a GIA stapler proximally and distally on the small bowel. The segment was then sent for permanent pathology.
Next, we lined the 2 parts of the small bowel next to each other, placed serveral popoff 2-0 silks to align the small bowel. At the end of the small bowel we made 2 enterotomy incisions, placed a GIA arm through each of these incisions, and fired the GIA staple, creating a common channel, We placed babcocks and then fired a TA stapler on top to close the area where we had placed the original stapler. ONce the anastomosis was done, we closed the mesentery with running 2-0 vicryl to prevent internal hernia. There was one area that had a serosal tear. We placed a couple popoff silks on this serosal area superficially.
Lastly, we placed the feeding J tube. We identified an area distal to the small bowel resection and distal to the serosal tear repair. We placed a pursestring and then with electrocautery into the small bowel placed a 12-french red rubber after cutting it and triimming off the end to the appopriate side holes. We thsi through the small bowel, secured it with a pursestrin, and then this with probably six popoff 0 silks, We made a stab wound in the left lateral abdominal wasll and were able to bring the feeding tube up throught it and secure it to the chest wall cirumferentially at the insertion place with remaining ends of the 0 popoff silks, as well as keeping it takced to the abdominal wall so there was no torision of this.
When we tried to identify the area for the pyloroplasty, we did some dissection. This was very difficult, and it was felt that it was not work the risk associaated with his anastomosis fro the prior esophagectomy. The area of the pylorius was likely underneath the xiphoid, deep inside th epatient towards the left rotated, and so for this reason we felt we could disregard the pyloraoplasty.
Hemostais was cheieved. close dthe incison with 2 runing PDS suters.
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