# Extralevator abdominoperineal resection with total mesorectal excision and mesh sling



## hpierce (Apr 17, 2012)

I am really struggling with this surgery. I was thinking maybe 45110-22 but then I wasn't sure it told the whole story?? What about the mesh sling?? Please Help!! Heather, CPC

DIAGNOSIS: Low rectal cancer.
PROCEDURE: Extralevator abdominoperineal resection with total mesorectal excision and mesh sling. 
PROCEDURE IN DETAIL:  Patient underwent outpatient bowel preparation with mechanical means and oral antibiotics. It was covered with IV antibiotics and pneumatic compression stockings, subcutaneous heparin, Foley catheter, orogastric catheter. After consent was obtained, he was taken to the operating room. General anesthesia was induced without difficulty. The abdomen was prepped and draped in usual fashion.  The patient was placed in a lithotomy. A midline incision was made with a knife, infraumbilical and working deep to this, I opened the fascia, introduced into the peritoneal cavity.  General survey was undertaken. Palpating the liver, I could appreciate no evidence of metastatic disease and none was found on CT scan. General survey of the peritoneum demonstrated no metastatic disease and I could not feel the tumor as it was palpable adenopathy. At this point, the root of the mesentery along the inferior mesenteric artery pedicle, I could scored the mesentery. I should say that I placed a Bookwalter retractor, but I scored the mesentery and isolated the inferior mesenteric vessels as I came off the aorta and clamped these proximally, distally, divided and ligated with 2-0 silk ties. The dissection was then undertaken using electrocautery into some element Harmonic scalpel. I scored the mesentery along the ureters going both left and right and coming up the mesenteric to the junction of the sigmoid and descending colon and divided  proximally and distally and divided and ligated with 2-0 silk ties. I came adjacent to the sigmoid colon and fired a contour stapler, thus stapling dividing the bowel. I then mobilized the sigmoid colon medially and taking down the lateral peritoneal reflection. Again, I identified the left and right ureter and spared these throughout the procedure. The entire procedure was done with sharp dissection, or Harmonic Scalpel, and I continued down again the presacral plane and coming down along the presacral plane in the avascular plane, continued on down. Again I essentially could not identify the tumor. I should say that at the beginning of the procedure, a 3-0 silk suture was used to suture close the anus. I continued down and dissected down using Harmonic scalpel in the ureter and continuing anteriorly, dissected off the peritoneum identifying the plane and could identify posteriorly the autonomic nerves and stayed just anterior to these. As I came down, I identified all lateral pedicles and out laterally these were divided with Harmonic scalpel. I continued the dissection down and ultimately identified the levators and the levators were divided with Harmonic Scalpel to avoid narrowing down at the level of the sphincters. When I dissected as far as I possibly could inferiorly keeping the mesorectum ______, I went down to perineum. A bi-elliptical incision was made around the anal verge encompassing the skin and the internal and external muscle.  At this point, using sharp dissection, some element of cautery, I dissected out into the perirectal fat and continued up external to the sphincter muscle.  I could appreciate that the tumor was in the left posterior lateral and I particularly make sure to stay away from it in this area, but there was no extension of the tumor out in the perirectal fat by preoperative imaging.  I continued dissection up and widely free until I encountered the division in the levators and was able to essentially roll out the rectum anteriorly and care was taken to avoid injury to the urethra.  I could identify from above the seminal vesicles and I came immediately posterior these as I had dissected down.  The specimen was then passed free.  Hemostasis was found to be adequate.  The incision was irrigated.  At this  point, I attempted to reapproximate the muscle along the pelvic floor.  This was somewhat difficult because the levators have been resected out widely.  The specimen did not have an hourglass shape, but was more directly tubular.  There was no involvement of the opening of the bowel or direct visualization of the tumor.  The margins were secure.  At any rate, I reapproximated he is able the fatty tissues of the pelvic floor. There was some laxity of the muscle and this was pulled together as able, but not much was mostly perirectal fat.  Two 19-French round closed suction drains were brought out the lateral buttock incisions and placed above this area.  These were secured in place with 3-0 nylon suture.  Ultimately, the skin was closed with staples and that went up to the abdomen.  At this point, it was essentially impossible to reapproximate the peritoneum as the gap was too wide and therefore a piece of Vicryl mesh was sewn into position using interrupted sutures of 3-0 Vicryl and care taken to avoid injury to the ureters.  I attempted to keep this adjacent to the abdominal wall and pelvic wall to avoid entrapment of bowel.  When this was completed, I took down the lateral peritoneal reflection to mobilize up the descending colon, until I identified an appropriate spot.  An elliptical incision was created in the abdominal wall.  On working deep to this, identified the rectus sheath.  This had a cruciate incision, placing a splint through the rectus muscle.  Babcock clamp was used to grasp the descending colon and deliver this out.  This was adequately excised.  At this point, all retractors were withdrawn.  The fascia was then closed with a running suture of #1 PDS and the skin closed with staples.  The colostomy was then matured by cutting out the staple line, everting the colon and interrupted sutures of 3-0 Vicryl placed. Bag was applied.  The patient was then extubated and returned to the recovery room.  Tolerated procedure well.  Estimated blood loss was maybe 350 cc.  Needle, sponge, and instrument counts were correct.


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## colorectal surgeon (Apr 17, 2012)

Ah, don't see that used too often!

44700	 Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum)
CPT assistant Nov.Volume 7, Issue 11, November 1997


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## hpierce (Apr 18, 2012)

Wow, thanks! So do you think I would still need the -22 modifier on the 45110? Or just use 45110 and 44700?

Heather, CPC


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## colorectal surgeon (Apr 20, 2012)

So an extralevator abdominoperineal resection is more extensive than a traditional APR so I would add the 22 modifier.  

Make sure your doc is noting in the op note that the procedure was more complicated than normal so a 22 is being used.


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## hpierce (Apr 25, 2012)

colorectal surgeon said:


> So an extralevator abdominoperineal resection is more extensive than a traditional APR so I would add the 22 modifier.
> 
> Make sure your doc is noting in the op note that the procedure was more complicated than normal so a 22 is being used.



Thank you!!!
Heather, CPC


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