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Thread: Return to OP XLapy Resection distal ileum

  1. #1

    Default Return to OP XLapy Resection distal ileum

    AAPC: Back to School
    Anyone agree with 44153 ??? pls help!

    PREOPERATIVE DIAGNOSIS: Pancreatic duct leak status post splenectomy with distal pancreatectomy.

    1. Pancreatic duct leak status post splenectomy with distal pancreatectomy.
    2. Multiple areas of infarcted bowel.
    3. Intraabdominal abscess.

    1. Exploratory laparotomy.
    2. Resection of the distal ileum.
    3. Extended right hemicolectomy.
    4. Distal pancreatectomy.
    5. Abdominal washout.

    SPECIMENS: Include
    1. Distal small bowel.
    2. Right colon.
    3. Distal pancreas.

    INDICATIONS: Pt underwent an exploratory laparotomy which resulted in a splenectomy and distal pancreatectomy as well as a left nephrectomy. Please see the separately dictated operative report for the details of that procedure. A JP drain was left in place. Postoperative he remained intubated and appeared to be septic with multiple periodic hypotensive episodes. He was febrile and was having a significant amount of fluids come out of his JP, which was placed in the pancreatic bed. The decision was made to return the patient back to the Operating Room to undergo a formal distal pancreatectomy to help control the pancreatic leak.

    DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room and placed in the supine position. A standard timeout was performed, indicating correct patient and procedure. The abdomen was then prepped and draped in the standard fashion. The staples from his previous midline incision were removed and the fascial sutures were cut. The abdomen was then entered. Of note, there was a significant amount of omentum adhered into the right lower quadrant, and the bowel appeared to be grossly edematous. The procedure began with running the bowel, which was traced to the distal ileum. Of note, in this area the bowel was thickened, twisted and stuck in the right lower quadrant. Once it was manipulated into the wound, it was noted to be quite concerning with multiple areas of necrosis. The necrosis extended through the terminal ileum, but did not include the cecum. Decision was then made to perform a small bowel resection including the cecum. The right colon was then mobilized medially along the white line of Toldt. The areas of proximal and distal transection were determined. The small bowel was then divided with a linear cutting stapler. The mesentery was divided using the LigaSure device and a large mesenteric vessel was identified and suture-ligated. The right colon was then divided with a linear cutting stapler and the mass was passed off field as specimen. Examination of the remainder of the small bowel noted no other abnormalities besides diffuse edema. The colon was examined and followed from the proximal transected region up to the splenic flexure where it was adhered into the previous splenic fossa. It was then traced along the left colic gutter to the rectum. Of note, the superior aspect of the entire colon appeared to be intact. The posterior aspect was then rotated and the colon was examined, and there was an infarcted area right at the splenic flexure with multiple areas of spotty necrosis and what appeared to be a large inflammatory mass in the left upper quadrant. It is my feeling that this spotty necrosis combined with the fluid from the leak led to a complete breakdown as the wall appeared to be nearly totally transected in that region. There was a significant amount of inflammatory material. Given that the left colon up to the splenic flexure appeared to be completely intact circumferentially and had what appeared to be good blood flow, and the right colon had the proximal transection as well as the splenic flexure region, the decision was made to extend the right hemicolectomy to the splenic flexure, leaving a long Hartmann's pouch. The colon was mobilized in a right-to-left fashion dividing the omental attachments of the lesser sac as well as mobilizing the stomach superiorly and away from the colon. The mesentery of the colon was divided again using the LigaSure device. Care was taken to ensure that the vessels of the SMA and SMV were identified and not injured during this process. The distal aspect of the transsection was identified and divided using a linear cutting stapler. The transverse colon was then passed off the field as part of the specimen "extended right hemicolectomy."

    The region of the left upper quadrant was more thoroughly examined. The remainder of the omentum had been significantly dissolved by the inflammatory process. There is significant amount of rind and what appeared to be the beginning of a left upper quadrant abscess. The abdomen at this point was copiously irrigated with 6 L of warm sterile normal saline. The pancreas was then examined at this point. The exact ductal leak could not be identified. A formal transection was determined to be appropriate. The splenic artery was identified and ligated using 0 suture. The pancreas was then transected using a TA stapler. The staple line was then oversewn using 3-0 PDS in a running fashion. The stomach was examined and there was some inflammatory rind in the posterior aspect with some serosal tears, which were repaired in Lembert fashion. The NG was manipulated into position. The remainder of the pancreas appeared to be intact and healthy. The small bowel was again run and examined, and there were no other areas of potential infarct or injury. The colon and rectum were examined and again no evidence of injury was noted. Decision was made to leave the divided bowel in place with a long Hartmann's, with plans to bring the patient back for reexploration and a formal ileostomy. The abdomen was then closed using an intraabdominal wound VAC.

  2. #2


    Maybe 48140 44160-52?

    Dr took terminal ileum, cecum, ascending and most of the transverse colon and closed it off (the Hartmann part). But he didn't do the ileum to the transverse colon anastomosis which I why I would -52. 44143 doesn't describe taking any ileum and describes a colostomy.

    Good Luck!

  3. #3


    Thank you for that. I will look those up. Much appreciated !

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