# Partial vs total colectomy/ ileostomy



## rachell1976 (Jun 17, 2010)

How would you code this? We are trying to determine if we should bill a total abdominal colectomy 44150 with a 52 modifier for reduced services.
Or an unlisted code.

We talked to the physician. No anastmosis were done. Just stapled the ends off. He did leave a portion of the descending colon, sigmoid & rectum.


PROCEDURE:  Laparotomy with extended right colectomy and ileostomy.

SURGEON: 

ASSISTANT:  

OPERATIVE FINDINGS:  There was a hard mass in the colon in the proximal
descending colon region.  The colon proximal to the obstructing lesion
was markedly dilated, particularly the cecum, which was a 12-15 cm in
diameter and lying in the left mid to left upper quadrant.  There were
several areas of serosal splitting of the cecum.  There were numerous
adhesions in the upper abdomen, particularly the right and left upper
quadrants from previous surgery.  What could be seen and palpated in the
liver, stomach, duodenum, and remainder of the colon and small bowel
appeared normal.

PROCEDURE NOTE:  After the induction of satisfactory general
endotracheal anesthesia, the patient was prepared and draped in a
sterile manner in the supine position.  The abdomen was entered through
a standard upper vertical midline incision, and after fairly extensive
lysis of adhesions, explored with findings as above.  The cecum was
replaced into the right lower quadrant and decompressed using an 18
gauge needle placed through a pursestring suture of 3-0 silk in one of
the tenia.  Dissection was begun in the mid to proximal descending colon
where the white line of Toldt was incised, and the proximal descending
colon freed medially using blunt dissection.  Fairly extensive lysis of
adhesions was required to complete mobilization of the splenic flexure
of the colon.  The transverse colon was mobilized by dividing the
gastrocolic ligament between 2-0 silk ligatures.  The transverse
mesocolon was then serially divided at its base using 2-0 silk
ligatures.  The middle colic artery was divided, and ligated with 2-0
silk ligatures.  Because of the condition of the right colon, and
particularly the cecum, I elected to do an extended right colectomy,
rather than a more limited colonic resection and colostomy.  The splenic
flexure and right colon were mobilized in the usual manner after a
fairly extensive lysis of adhesions.  The right ureter was identified
and preserved.  The mesocolon of the ascending colon was serially
clamped, divided, and ligated with 2-0 silk ligatures.  The descending
colon was divided distal to the obstruction using a GIA 60 mm stapler.
Once the colon was completely mobilized, the ileum was prepared by
dividing the mesentery to the wall of the ileum, with hemostasis
achieved using 2-0 and 3-0 silk ligatures.  The GIA 60 stapler was fired
across the ileum, approximately 4 cm proximal to the ileocecal valve.
The specimen was removed from the field.  A search for bleeding was
made, and the only significant source was a small capsular tear in the
anterior aspect of the spleen, which was quite mobile.  Bleeding was
controlled using thrombin-soaked Gelfoam, 2 small pieces placed in the
small capsular tear in the spleen and pressure applied with laparotomy
pads.  After packing spleen, an ileostomy site was prepared in the right
lower quadrant by incising a circle of skin and carrying the incision
down to the fascia, which was divided transversely.  The rectus muscle
fibers were separated, and the transversalis fascia and peritoneum
incised, and the opening through the abdominal wall enlarged to admit 2
fingers.  The ileum was brought out through the ileostomy site in a
tension-free manner, and the ileum tacked to the abdominal wall using
interrupted seromuscular sutures of 3-0 silk.  The spleen was
reinspected, and  hemostasis was secure.  The spleen was returned to its
usual anatomic position.  The abdomen, with the exception of the left
upper quadrant, was irrigated copiously with saline.  Careful search for
bleeding was again made, and none identified.  The midline incision was
reapproximated using running #1 Maxon loop for the myofascial layer, and
stainless steel staples for the skin.  A standard Brooke ileostomy was
fashioned by excising the staple line on the ileum,  everting the ileum,
and suturing full-thickness ileum to side of the ileum to subcuticular
skin circumferentially, creating a 2-3 cm everted ileostomy.  Sterile
dressing was applied over the midline incision, and an ileostomy
appliance over the ileostomy.  The patient was awakened and sent from
the operating room in stable condition.

ESTIMATED BLOOD LOSS:  300 mL

Sponge and needle counts were correct.


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