# Takedown of intestinal bypass w small bowel resection



## ksb0211 (Jun 28, 2011)

Hey, all!  Thanks for checking this out.  I'm hoping to hear some other opinions on this one.  Attached is the scrubbed op report.  As you will see, although he doesn't mention it in the "PROCEDURE:" part of the op report, he does mention that they also did a liver biopsy.  Ugh. LOL  

PREOPERATIVE DIAGNOSIS
Small bowel obstruction.

POSTOPERATIVE DIAGNOSIS
Perforated intestinal bypass.   569.83?

PROCEDURE
Take down of intestinal bypass with small bowel resection and lysis of adhesions.

DESCRIPTION OF PROCEDURE
....A midline incision was made and we entered the abdominal cavity. We defined some distended proximally and collapsed bowel distally.  The distal bowel was misshapen and quite stenotic in appearance.  As we traced the stenotic bowel and the dilated bowel up we could see that they entered into the colon and right at that point there was an adhesive band. Took down this band and as we did so we saw that there was a chronic abscess with some exudative material beneath it demonstrating what looked to be a bowel perforation referrable to this adhesive band.  We realized that we would need to take down this ileal bypass and so we removed the ileum from the ascending colon using a GIA stapler with green staples. We made about a 75 millimeter firing of that stapler which took down the bypass in its' entirety.  We then oversewed that using sutures of 3-0 silk.  Once that was done we could really look at this bowel now and trace it back up into the distal ileum.  The patient had very short intestines and it was obvious that the surgeons back in 1978 were trying to preserve some degree of intestinal function by making a bypass rather than a resection and actually this has served her well over the years but looking at the current situation with perforation, defunctionalized gut at this point, we realized that were going to have to resect some of this gut which had been defunctionalized and actually problematic for her over the years with blind loop syndrome and the like.  We looked at the most distal portion of the ileum and that actually looked pretty decent and we felt that there was enough lumen to accommodate the patient and so what we did was we just resected this, the area of perforation along with some of this very diseased looking atrophic looking intestine. We took down about a foot of it and then at that point we were able to make and end-of-ileum rather side-to-side functionally end-to-end anastomosis with the most distal ileum probably somewhere around the mid jejunum of what was left of her intestinal tract.  We made our anastomosis with the 75 millimeter GIA and considered actually coming back up further onto the cecum and making sort of a intestinal plasty, elected against that because we were afraid we were going to get dumping directly into the ileum which would be problematic and so what we did is we left it as it was, a standard anastomosis with 75 millimeter green staples and then closed the resulting rent with TA60 but not before placing a Yankauer through the distal ileum into the colon and we were able to get that in there easily and we felt that this the intestine was open adequately to allow flow into the distal ileum. Once that was done, we closed the mesenteric defect. We had taken down the mesentery with 2-0 silk and then we carefully reordered the bowel back into the abdominal cavity, what there was of it, and covered it with omentum. Irrigated copiously because there was not really much spillage. All this was contained. There was no frank peritonitis. There was no abscess.  We went ahead and irrigated, aspirated the fluid and made sure we had a dry abdomen or at least as dry as we could get it with the sucker.  _Went back up to the liver and saw that there were some masses on the liver. One of these we took down was just a cyst wall and we sent that off for analysis and so there was effectively a liver cyst wall biopsy._  We went ahead and we irrigated, aspirated and then turned our attention to closure.  We closed with #1 PDS double-stranded in two layers followed by wound irrigation, followed by skin staples.  The patient tolerated the procedure well.


----------



## surgonc87 (Jun 29, 2011)

I had a similar case yesterday.  Use

44130 
+47001( 44130 is a PX of this add on)

MS


----------



## cmartin (Jul 11, 2011)

It's pretty hard to follow, but there's definitely mention of a resection & an anastomosis, so I'd think you've got a 44120 in there anyway...


----------

