# subtotal colectomy ?



## codedog (May 9, 2017)

Stuck on this one , thinking 44207, not sure if i can bill the hernia , the rt sid e of colon is absent so thinking this cant be a total so looking at 44207 , please let me know what anyone thinks 

PROCEDURE PERFORMED: Laparoscopic subtotal colectomy with ileorectal 
anastomosis and incisional hernia repair..

POSTOPERATIVE DIAGNOSIS: Colon adenoma.
.

TECHNICAL PROCEDURE PERFORMED: Ileorectal anastomosis, incisional hernia 
repair, and the anastomosis was created with a 25 mm circular stapler in an 
end-to-end fashion.
: 

DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area 
where consents and site verification forms were reviewed. Questions were 
answered. Risks and benefits of the procedure were explained to include 
bleeding, infection, damage to surrounding structures, need for repeat 
procedures, possible anastomotic leak, and risks of anesthesia. She agreed and 
wished to proceed. She was taken to the Operating Room, placed on the Operating
Room table in the lithotomy position. After general anesthesia had been 
induced and a Foley catheter was placed, a rectal washout was performed. An 
operative timeout was discussed and the procedure began. We initially began by 
making a 7 cm lower midline incision using a #10 blade and dissecting taking 
down through the subcutaneous tissue. We entered into the abdomen under direct 
vision and took down some filmy adhesions that were noted from the omentum to 
the anterior abdominal wall. Once we cleared all the adhesions, we placed a 
Gelport into the incision and placed a 12 mm trocar just inferior to the 
umbilicus for the camera port. We then began our pneumoperitoneum and took down
additional adhesions using the EnSeal device after a 5 mm trocar was placed in 
the left lower quadrant. We then placed another 5 mm trocar in the right lower 
quadrant and began the mobilization process of the right and left colon. The 
right colon was noted to be absent given the patient had a previous right 
hemicolectomy and the hepatic flexure was then mobilized medially by dividing 
the lateral attachments using the EnSeal device. The omentum coming from the 
transverse colon was previously excised prior to beginning laparoscopically and 
the remaining omentum was divided using the EnSeal device as well and the 
hand-assist technique. The left colon was taken down using the EnSeal device as
well from a lateral to medial aspect and the mesentery was divided using the 
EnSeal device as well to the transverse colon. The middle colic vessels were 
identified. These were taken high given this was a potential cancer case in 
order to get adequate lymph nodes. We continued along the mesentery of the 
transverse colon until we fully mobilized the colon and we were able to bring 
the transverse and descending colon out through the lower midline incision. We 
then identified an area just proximal to the ileocolic anastomosis and divided 
this using a Furness clamp and identified another area at the rectosigmoid 
junction and divided this in a similar fashion using a Furness clamp as well. 
The colon was then sent off to the pathologist as a specimen. The anvil of the 
circular stapler was then placed into the proximal aspect of the small bowel and
secured using the Monosof sutures that had been previously placed using the 
Furness clamp. We then used a 25 mm stapler and brought this in through the 
patient's anus and up into the rectum and deployed the spike, secured the 
divided area of the rectosigmoid junction, and secured this portion of the 
rectum to the spike using the previously placed Monosof sutures. The ileum was 
then secured to the rectosigmoid junction and the anastomosis was created. An 
air leak test was performed and this was negative. There were adhesions to the 
small bowel, which prevented us from fully mobilizing this and these were taken 
down sharply without injury to the small bowel. We then instilled local 
anesthetic in the fascia. Prior to closing, we noticed there was a large 
incisional hernia noted at the superior aspect of the patient's previous 
incision. This was closed primarily using running #1 PDS suture and the fascia 
was closed in a similar fashion from above and below. The skin was then closed 
with 4-0 Monocryl subcuticular sutures and the trocar sites were also closed in 
a similar fashion using 4-0 Monocryl. Dermabond was placed over the incision. 
The patient tolerated the procedure well


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## lindsey.hansen (May 9, 2017)

My opinion would be 44210, regardless of the previous hemicolectomy they still did a subtotal colectomy. And yes you can bill the hernia 49654 as far as encoder says there is no CCI Edit.


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## codedog (May 9, 2017)

thank you


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