# Sigmoid Colectomy W/Primary Anastomosis



## ch81059 (Mar 6, 2014)

Could I get a suggestion on what code you would use for this?  I am bouncing back and forth between 44140 and 44145.  From the wording in red, it seems to me that there was still some sigmoid colon left.  Would that still be considered a coloproctostomy?  Any suggestions or input would be appreciated.

PREOPERATIVE DIAGNOSIS
Sigmoid diverticulitis.

POSTOPERATIVE DIAGNOSES
Sigmoid diverticulitis.

PROCEDURE
Sigmoid resection with primary anastomosis using EEA stapler.

INDICATIONS FOR THE PROCEDURE
This is a 58-year-old male well known to Dr. XXXXXXX who had a
nephrectomy in the past who presents with left lower quadrant pain.  The
patient had a CT scan which showed non-perforated diverticulitis which
was treated medically with antibiotics and rest.  At this point, the
patient was seen in clinic for elective sigmoid resection to be done
laparoscopic versus open.

PROCEDURE IN DETAIL
After proper consent was obtained and the patient agreed the patient was
brought to the operating room and placed in the supine position.  Once
anesthesia was administered, the patient was prepped and draped in the
usual sterile fashion.  At this point an optical trocar was used to
enter the abdomen in the supraumbilical region.  The pneumoperitoneum
was obtained to 15 mmHg.  The abdomen was inspected and noted to have
omentum stuck to the previous hernia repair in the right upper quadrant
and a secondary omental adhesion in the left lower quadrant.  At this
point a second 5 mm trocar was placed in the right lower quadrant and
the area was dissected and there was noted to be a fairly dense adhesion
in the left lower quadrant.  At this point a third 5 mm trocar was
placed between the umbilicus and the right lower quadrant and at this
point the omentum was dissected off of the peritoneum in the left lower
quadrant.  There was noted to be a small diverticula that was adhered to
the peritoneum.  After taking down this diverticula there was noted to
be copious amounts of purulence coming from the preperitoneal space.
Around the region of the dome of the bladder there was noted to be a
small perforation in the sigmoid colon.  At this point the decision was
made to open up the patient and given his previous history of
nephrectomy and renal insufficiency this would be the best option for
the patient to open the patient using a lower midline incision.  A large
Alexis retractor was placed in the left colon.  The left white line of
Toldt was opened up and the sigmoid was mobilized.  At this point a 75
GIA blue load was used to transect the descending colon and the LigaSure
was used to take down the sigmoid all the way down to just proximal to
the peritoneal reflection leaving an approximately 2 cm cuff of distal
sigmoid.  There was noted to be a portion disease that was fairly
proximal on the sigmoid and the distal sigmoid was noted to be very
healthy.  Also, the distal descending colon was noted to be very healthy
at this point with no inflammation.  The contoured stapler was used to
take down the distal sigmoid and the LigaSure was used to take down the
mesentery.  At this point the specimen was handed off.  Good healthy
descending colon was noted on the proximal aspect and good healthy
distal sigmoid cuff and rectum were noted on the distal aspect.  At this
point a pursestring device was used to secure a pursestring suture
around the descending colon and a 29 mm anvil was placed in the
descending colon.  At this point, Dr. XXXXXXX on the bottom side and
dilated up the rectum without any issues.  A 29 mm dilator passed
easily.  At this point an EEA was passed up through the rectum to the
staple line.  The spike was passed just posterior to the staple line and
the EEA anastomosis created.  At this point 2 good donuts were resected
from this anastomosis.  There was noted to be no leak on a bubble test.
At this point the abdomen was irrigated out using copious amounts of
normal saline.  The fascia was reapproximated using a #1 looped PDS.
The skin was reapproximated using staples and the previous 5 mm trocar
sites were reapproximated using staples.  The patient tolerated the
procedure well.

Thanks!


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## ch81059 (Mar 7, 2014)

Any ideas????


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## nrichard (Mar 11, 2014)

*44140*

The areas you have in red are just notation to his findings, he?s not removing these areas. 
44140 is for partial colectomy with anastomosis. There is no stoma created.
44145 is when the proximal portion of the rectum is removed, he stopped at the distal segment of the sigmoid colon, not into the rectum yet.


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## cynthiabrown (Mar 11, 2014)

44145   low amastomosis


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## Mar (Mar 11, 2014)

Hi,
I would use 44145 due to the wording by the physician...

"At this point a 75 GIA blue load was used to transect the descending colon and the LigaSure was used to take down the sigmoid all the way down to just proximal to the peritoneal reflection leaving an approximately 2 cm cuff of distal sigmoid."

The peritoneal reflection is just above or below the rectum area (it depends on the picture that you are looking at).


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