# revision of left ureteroileal anastomosis,looposcopy, open



## tgenia (Dec 28, 2012)

Hi, I was wondering if someone would be able to help me with this procedure, I have a few codes 44380,50690 but not sure on the main procedure 50780? Please help
Thanks so much

PREOPERATIVE DIAGNOSIS 
Stricture, distal left ureter at the ureteroileal anastomosis. 


DESCRIPTION OF PROCEDURE
Exploratory laparotomy, revision of left ureteroileal anastomosis,
looposcopy. 


ANESTHESIA
General.


INDICATIONS
This is a 65-year-old man who underwent a cystectomy and ileal conduit for
invasive bladder cancer. He did well except that about 6 months
postoperatively, he developed an ureteroileal anastomotic stricture. He had a
stent placed and had it dilated by interventional radiology. However, the
stricture did not resolve, and he has continued to have the stents changed.
He had a recent urine culture showing organisms both sensitive to Levaquin,
which he was placed on one week preoperatively. He decided to go to a
definitive repair at this time. He has had no evidence for recurrent cancer.
I reviewed the images again preoperatively. This shows a stricture to be the
distal 2 cm of the left ureter just before the ileal loop. It shows a normal
right ureter. It goes just behind the area of the ureteral stricture and then
into the loop. He received a bowel prep preoperatively. 


DESCRIPTION OF PROCEDURE
After satisfactory general anesthetic, the patient's stoma appliance was
removed and he was prepped and draped in a sterile fashion. I placed a Foley
catheter into the ileal conduit alongside the stent, and then we made a
midline incision starting at the umbilicus and going inferiorly, but later
extending up several centimeters further to get further exposure. This was
carried down through the midline of the rectus fascia and the peritoneum was
entered. There were some adhesions, which were taken down. The ileal conduit
was identified on the right side. It was not injured. I dissected down along
the ilial conduit until I got to the butt end which was densely adherent to
the sacrum. I could feel the stent in the ileal conduit and I could feel
where it came out of the conduit. There were dense adhesions in this  area. I
dissected the distal ureter free anteriorly. However, it was very difficult
to get posterior to the ureter. Being concerned that I did not want to injure
the right ureter, which I knew went just behind the distal left ureter, I
decided to expose the left ureter higher up. I then freed up the descending
and sigmoid colon laterally and reflected those, and then identified the left
ureter with its stent. I dissected the ureter almost to up to the kidney and
then distally down to the hiatus in the sigmoid mesentery and then through
this area. Moved the colon back and forth several times to make sure we had a
good dissection. I was able to dissect the ureter in its entirety down to the
area of the stricture. The distal 2 to 3 cm were densely adherent posteriorly
to the sacrum. I was able to free it up off the left common iliac vein.
However, we were concerned that if we freed up to the entire distal ureter,
we could compromise the right ureter, which was normal. We could also get
into serious problems with bleeding. I then performed looposcopy after giving
the patient 10 mL of indigo carmine intravenously. We identified the right
ureteral orifice effluxing blue urine quite freely. This is clearly separate
from the stent. I then severed the distal left ureter about 3 cm above the
ilial loop, removed the indwelling stent, and oversewed the remaining distal
end of the ureter with 3-0 Vicryl. I was able to bring the ileal conduit over
to the ureter. The ureter itself was not long enough to come all the way over
to the loop itself. I was able to bring a portion of the antimesenteric
border of the loop over to the distal ureter without any tension. I made a
small incision in the antimesenteric border and placed stay sutures in each
corner after spatulating the ureter and the stay sutures were 3-0 Vicryl. I
then performed a running anastomosis on each side with 4-0 Vicryl. Prior to
closure, I did place a 6-French single pigtail catheter. This irrigated
nicely without any leakage from the anastomosis. A careful search for
hemostasis was made which was excellent. Wound was copiously irrigated with
triple antibiotic solution. Intra-abdominal contents were placed in their
normal anatomic position. There was no injury to the bowel, and as mentioned
before, no injury to the right ureter. The fascia was infiltrated with 40 mm
of 0.5% Marcaine. Fascia was closed with running looped on 0 Maxon; one
beginning at the top, one beginning at the bottom, and tied together in the
middle. Skin was closed staples. The stoma appliance was placed. I should
also mention that prior to closure, I did place a 15-French round
Jackson-Pratt drain and exited through separate stab incision on the right
side. This was placed near the anastomosis. The patient was awoken from
anesthesia and went to the recovery room in good condition. Blood loss was
200 mL. 


It should be coded as a complex operation.  It was difficult because of dense
scar tissue encountered requiring very extensive and  careful dissection. 
The end result was good.


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## Kelly_Mayumi (Jan 14, 2013)

50800


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