# Creation of end colostomy and mucous fistula



## Nsetla01 (Mar 12, 2015)

Can someone please help me! My doc is going in to finish a prior colectomy. He's completing the colostomy and mucous fistula. Code 44144 includes the partial colectomy, not sure how this should be coded. Thanks in advance!:D

The patient was placed in the supine position and prepped and draped in the standard usual fashion.  Next, the old wound VAC and material were removed and the bowel was exposed.  Next, we turned out attention towards the right upper quadrant where the previous abdominal packs were left.  As we were running the small bowel and got close to the right upper quadrant, we visualized abdominal packs.  Some normal saline was applied to give us the ability to pull the packs and the packs were removed without difficulty.  The tissue bed underneath was evaluated and found to be hemostatic.  We evaluated the old duodenal injury which was repaired primarily and it was deemed to be in good shape.  No further repair was deemed necessary.  We also evaluated the porta hepatis.  There was no bleeding or active leakage of bile, but bile staining was seen. Next, we took the greater omentum available and mobilized it near the previous injuries to provide added security in case something leaks. We pulled it near the old duodenal injury, as well as porta hepatis, and secured it in the vicinity with 3-0 interrupted Vicryl sutures.  Next, the blind loop of the ascending colon was seen.  We took the time to mobilize part of it to free it up enough in order to bring up an ostomy on the right side.  After this was done, our attention was turned to the left blind loop of the transverse colon which was mobilized enough in order for it to be brought up on the opposite side for a mucous fistula.  Care was taken to ensure hemostasis with electrocautery along the way.  Next, we created the opening for the ostomy on the right side.  With electrocautery, an approximately 2-cm diameter circle was incised with cutting electrocautery.  Dissection was carried down to the fascia with coagulation electrocautery.  Next, the fascia was entered and Kelly clamps were used to bluntly spread through the muscle fibers of the rectus abdominis and the rest of the abdominal wall muscles, penetrated through into the peritoneal side.  Next, the opening was dilated by blunt dissection with fingers until enough of was freed in order to bring up an ostomy through it.  Next, the ascending colon was pulled through the opening and secured in place with a Babcock.  Next, the same process was undertaken on the left side of the abdomen where an ostomy opening was created and the transverse colon was brought through that hole and secured in place with a Babcock for the moment.  Afterwards, we proceeded with J-tube placement.  We ran the small bowel until we found the ligament of Treitz.  Approximately 10-15 cm below it, we decided to make enterotomy.  We passed a 16-French red rubber catheter which was secured in place with a pursestring suture.  Next, we passed the red rubber catheter through the abdominal wall, on theupper left quadrant, underneath the ribcage.  Three to four 3-0 Vicryl sutures were used to tach the jejunum to the abdominalwall, where the jejunostomy tube was pulled through.  At this stage, we called in x-ray which brought in the C-arm and took pictures of the patient's chest and abdomen in order to ensure no more packs were left in the abdominal cavity. None were seen. Next, we turned our attention towards the possibility of closing the patient's abdomen.  Judging by our ability to bring the fascial edges close together, it seemed feasible without too much tension.  So, we proceeded with fascial closure with a 1.0 PDS suture.  We started to close the incision from the top to the bottom, 3 total  PDS sutures were used in the fascia.  The fascia came together nicely without tension. Next the end colostomy and mucous fistula ostomy were matured, and sutured with 3-0 vicryl. Ostomy appliances were applied. Next, we decided to not staple the skin, but put on an incisional wound VAC instead.


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## cynthiabrown (Mar 16, 2015)

Did he do first surgery? Did you append 52 mod?


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## Nsetla01 (Mar 18, 2015)

First sx. actually hasnt been billed yet. Same group of physicans, here is the note. Thank you so much for the help!!!



PRE-OPERATIVE DIAGNOSIS: A gunshot wound to the chest and abdomen with injuries to the heart, diaphragm, liver, portal system, inferior vena cava, right kidney, and internal mammary artery s/p exploratory laparotomy, repair of inferior vena cava, right nephrectomy and abdominal packing


PROCEDURE:  Exploratory laparotomy, removal of abdominal packs, segmental resection of hepatic flexure of the colon, partial debridement of the second portion of the duodenum with primary repair and partial resection of the left lobe of the liver, placement of new packing and JP drain placement.  


ANESTHESIA: General endotracheal anesthesia


ESTIMATED BLOOD LOSS:  100 mL


SPECIMENS: Necrotic liver, ischemic colon (hepatic flexure)


COMPLICATIONS:  None


CONDITION:  Critical


INTRA-OPERATIVE FINDINGS: Several packs were removed. Part of the left lobe of the liver was necrotic, there was necrosis of the second part of the duodenum as well as the hepatic flexure of the colon. The liver and inferior vena cava repair sites were intact. The right retroperitoneum was hemostatic. 


DESCRIPTION OF PROCEDURE: 
The patient was brought down to the operating room and placed in the supine position on the operating room table. Pneumatic air stockings were applied to bilateral lower extremities. General endotracheal anesthesia was induced without complication. The patient's abdomen was then prepped and draped in the usual sterile fashion using. If the patient had not already been started on therapeutic antibiotics upon admission, it was ensured that the patient was given a dose of antibiotics prior to incision. A time-out was then performed identifying the correct patient and correct procedure.


The Abthera wound vac was removed and the previously placed packs were removed serially. There was no active bleeding identified. The previously repaired vena caval injury was intact. Examination of the portal triad showed no active bleeding or bile leak. There was necrosis of a portion of the left lobe of the liver with no active bleeding identified. After all the packs were removed, we started mobilizing and running the small bowel and colon starting from the ligament of treitz. There was an ischemic area of the colon identified at the hepatic flexure as well as a very thin necrotic anterior wall of the second portion of the duodenum with impending perforation. We proceeded to perform segmental resection of the ischemic portion of the colon. We used a 75 mm GIA blue load stapler to resect the colon and the mesentery was divided serially using a series of clamps and vicryl ties. The colon was sent to pathology. We then turned our attention to the duodenum. The necrotic portion of the duodenum was sharply debrided and primarily repaired horizontally in two layers using vicryl and silk interrupted sutures. The repair appeared intact at the end of the procedure. The necrotic portion of the left lobe of the liver was resected using Bovie cautery and it was sent as specimen to pathology. The liver remained hemostatic at the end of the procedure. The abdomen was then washed out and hemostasis was achieved to satisfaction. Packs were left in at the bed of the right renal cavity. We decided to leave the colon in discontinuity and leave the abdomen open. An abthera wound vac was placed. The patient tolerated the procedure well. He remained in a stable but critical condition. He was left intubated and transported to the intensive care unit.


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