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Thread: Hand assisted wide excision small bowel distal ileal neoplasm

  1. #1

    Default Hand assisted wide excision small bowel distal ileal neoplasm

    AAPC: Back to School
    Just want to verify that I have this correctly. I always get nervous when it comes to small bowel resections. Ugh. Thanks for taking any time to take a look at this and let me know what you think.

    Carcinoid small bowel.

    Hand assisted wide excision small bowel distal ileal neoplasm.

    The patient was brought to the operating room. After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. After attainment of sufficient general anesthesia, a 5 mm incision was made just above the umbilicus and we entered the abdominal cavity with a Veress needle. We insufflated to 14 mmHg, placed a 5 mm port. Carried out a brief intraabdominal exploration, which was really pretty much unrevealing. Placed a 5 mm port over to the left lower quadrant and we got a better look, moved the camera over there and saw that there was a spot on the distal ileum. We had looked at this patient's CT scan just prior to taking her to the operating room and gone over it with Dr. XXXXX and looked to see where this lesion might be we had sort of an idea were it might be in the patient's abdominal cavity, although the CAT scan was some time ago. We could see that this looked umbilicated and when we could touch it, it felt a little bit hard. This really raised our suspicions was that this might be a malignancy. We went ahead and brought the area up and made a small 7 cm incision, brought the area up using a Babcock and then just sort of wedged it out. It the looked umbilicated and once we got up it looked like it was just under 2 cm in diameter and we sent that down for pathologic evaluation. Pathologic evaluation suggested that this was a carcinoid. We had been waiting at this point and while we waited we extended our incision. Our feeling was that this was likely to be a carcinoid and we ran the small bowel throughout to make sure that we were not missing any other lesions in the small bowel. Once that was done we got the diagnosis back that this was indeed a carcinoid and we just resected about a foot of bowel and all of its mesentery, and as we got up to the root of the mesentery we saw 2 areas of lymphadenopathy which were grossly suspicious. We made sure we stayed away from those and as we resected them that they would come up with our specimen and we took out basically an en bloc resection, sending down the down the bowel which had been divided in one location for the original specimen.

    We used GIA staplers throughout and when we originally sent our sample we fired a GIA both proximally and distally and sent about a 3 cm piece of distal ileum down. While we were waiting for we ran the small bowel and then once we got confirmation that this was a carcinoid we fired a GIA distally and then another GIA proximally and then made a wedge shaped resection taking out about a little bit more than a foot of small bowel on making sure that we took our resection down to the mesenteric root, we are pretty happy with this. We had a large clamp across the end of the distal mesentery. There were some large blood vessels in that area and that fell off which resulted in our blood loss about 100 mL. We got that under control real fast about 4 figure-of-8 sutures of 2-0 silk. Once that was done, we then used Harmonic scalpel taking down the mesentery and making sure that we doubly burned on the non-specimen side so that we had sort of a double area before we did our resection. Handed off the resected material and then opposed the small bowel, fixed the antimesenteric border with a series of 3-0 silks then introduced a GIA 75 mm with green staples, fired it and then closed the resultant rent with a TA 60 with green staples, then closed the mesentery with a running locking suture of 2-0 Vicryl, dropped that back within the abdominal cavity, closed that wound. Then, went back in with the laparoscope and really got a good look at the liver. We did not see any hepatic abnormalities. There was no other evidence of any other spread and our palpation when we were going in feelings for the bowel suggested nothing internally that we could not see. We then irrigated the wound, closed with deep sutures of 3-0 Vicryl followed by running subcuticular suture of 4-0 Vicryl in all locations. The patient tolerated the procedure well.

  2. #2


    I'm thinking 44120 and 44121. Anyone agree or disagree? I'm hoping that I'm not leaving anything out.

  3. #3
    Join Date
    Apr 2007


    I would say 44120 only since only one anastomosis was done.

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