# lap diverting ascending colostomy



## lindacoder (Oct 9, 2014)

Medicare patient underwent the following:

PREOPERATIVE DIAGNOSIS:  Peritoneal carcinomatosis with sigmoid colon  obstruction.

POSTOPERATIVE DIAGNOSIS:  Same.

PROCEDURE:  Diagnostic laparoscopy, laparoscopic diverting loop ascending  colostomy, mobilization of the hepatic flexure of the colon, repair of  transverse colotomy, repair of cecal colotomy, lysis of adhesions, lasting  greater than 30 minutes, intra operative anterograde colonoscopy.

ANESTHESIA:  General.

SPECIMENS:  None.

FINDINGS:
1.  Diffuse ascites.
2.  Peritoneal studding to multiple surfaces.  The entirety of the colon was  distended.  There was an adhesed loop of small bowel to the anterior abdominal  wall that was adhesed by tumor mass.  A portion of the posterior rectus sheath  was taken down with this to free this mass and prevent it from being tethered  anteriorly.  Once this was taken down, there was no evidence of obstruction at  this point.
3.  There was a question as to whether there was an additional obstructed area  at the hepatic flexure as this area with grasper felt thickened and indurated.  Once the loop colostomy was brought up, an intraoperative colonoscopy was  performed.  This hepatic flexure was able to be traversed and distended the  distal bowel, indicating patency.
4.  Very difficult airway requiring GlideScope intubation.

INDICATIONS FOR PROCEDURE:  The patient is a 54-year-old female with a known  history of peritoneal carcinomatosis.  She has developed symptoms of  increasing abdominal pain and distension as well as nausea and vomiting.  A CT  scan confirmed an obstruction of the sigmoid colon and diffuse peritoneal  seeding.  Given this fact, we discussed proceeding with a palliative  intervention of a diverting colostomy.  The patient is morbidly obese as well  as has significant ascites and distention from the underlying obstructive  process.  Given this fact, we discussed proceeding with a laparoscopic repair  with a potential conversion to an open procedure.  The risks, benefits and  alternatives of procedure were discussed with the patient and she wished to  proceed.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room  theater.  She was placed in the supine position.  She underwent preoperative  DVT prophylaxis with Lovenox as well as SCDs.  General anesthesia was induced.  Preoperative antibiotics were administered.  A Foley catheter was placed.  The patient's abdomen was then prepped and draped in normal sterile fashion.  A right lateral abdominal incision was then made.  Under countertraction, an  optical viewing trocar was placed.  Pneumoperitoneum was then established to  14 mmHg.  The abdomen was then evaluated.  There was found to be diffuse  ascites.  This was aspirated.  An additional 5 port was placed in the right  upper quadrant.  There was an adhesion that precluded easily visualization of  the left side of the abdomen.  We were initially able to work around this to  put additional ports.  A 5 port was placed in the right upper abdomen.  With  placement of this, this did penetrate the transverse colon.  Suction was  subsequently introduced through this and this decompressed the colon which  then aided in the remainder of the procedure greatly.  A grasper was then used  to elevate the transverse colotomy.  The right lower quadrant trocar was then  exchanged for a 12-port and the colotomy was stapled closed with a blue load  GIA stapler.  The remnant was removed and discarded.  Two additional 5 ports  were then placed in the left abdomen.  In order to fully visualize the colon  and to be able to maneuver, we did have to take down one area of small bowel  that was adhered to the anterior abdominal wall by tumor mass.  We stayed high  along the abdominal wall and did take down a portion of the peritoneum and  posterior rectus sheath.  Once this was all freed, the underlying small bowel  was visualized.  There was found to be no evidence of small bowel injury in  this area, was not obstructing this loop of bowel.  Given the fact that this  was broad-based and that there was no obstruction, we did not actually resect  this tumor mass that she has diffuse seeding and it would not affect her  overall prognosis.

Next, the right colon was identified.  At the hepatic flexure, there was a  questionable area of thickening and concern as to whether this area was  obstructed as well.  We then contemplated a transverse colostomy, but it was  concerning that there may be another obstructive lesion in the hepatic  flexure.  Given this fact, we proceeded first with a diverting ascending  colostomy with the plan to evaluate colonoscopically and if needed could have  a second diverting ostomy.

The right colon was significantly distended.  This was retracted medially and  the white line of Toldt was incised.  This was very thickened and edematous.  This was incised with the Harmonic scalpel.  The hepatic flexure was then  mobilized in a similar fashion.  We elected to bring the ascending colon up  the diverting ostomy.  A defect was made in the mesentery to be able to place  a Penrose drain and bring this loop up.  However, with attempt at this, a  colotomy was made.  We subsequently were able to identify this area and free  it from the surrounding fat.  It was then closed with a blue load stapler.  We  then thoroughly evaluated this area and there was found to be no other  evidence of colotomy.  The Penrose was then placed deeper through the  mesentery and then without incident.  A 12-port was placed in the right upper  quadrant at the planned location of diverting ostomy.  The appendix was  grasped through this.  At this point, we then turned our attention to the  exterior abdomen.  A disk of skin was removed from this port site.  The fascia  was then incised cephalad and caudally.  The ascending colon was able to be  brought out through this site.  The staple line from the colotomy was found to  be intact and there was no other evidence of injury.  The colon was very  thickened and edematous and somewhat difficult to bring through the defect,  but this was successfully done.  An ostomy bridge was placed and secured with  a nylon suture.

At this point, all other wounds were protected.  A transverse colotomy was  made in the planned orientation of the how this would be matured.  We then  proceeded with colonoscopy through the diverting loop.  The lumen was  visualized and this was able to pass the hepatic flexure which had now been  mobilized.  We then looked in 1 skin laparoscopically and the distal bowel was  dilated with air confirming patency.  This awl was then aspirated and the  colonoscope passed off.  While the wounds remain protected, the colostomy was  then matured in rosebud fashion with 3-0 Vicryl.  The ostomy bridge was  secured to itself with nylon suture.  Gloves were changed and all skin sites  were then closed with 4-0 Monocryl in a subcuticular fashion.  The right lower  quadrant 12 port site fascia was closed with a 2-0 Vicryl using a transfascial  suture device looking in laparoscopically.  Pneumoperitoneum was then released  and all trocars removed.  All skin sites were closed with 4-0 Monocryl in a  subcuticular fashion.  An ostomy appliance was placed.

The patient tolerated the procedure well.  There were no complications.  All  counts were correct as reported to me at the end of the case.


I'm thinking all I can do is 44188 for lap colostomy with a 22 modifier for the extra time on adhesions. Hepatic flexure mobilization is not codable and the repairs were done to colotomies that happened trying to perform the surgery and the anterograde colonoscopy was making sure it all connected and there were no leaks. 
Any thoughts??????


----------



## cynthiabrown (Oct 14, 2014)

Exactly!!!!


----------

