# PLEASE HELP Colostomy takedown with colon resection and coloproctostomy



## Ami Denney (Dec 16, 2014)

I could really use some help coding the below op note. I've ran several different codes through my notes but nothing seems to match up. I think I'm over thinking it.

PREOPERATIVE DIAGNOSIS: Status post colon resection for cancer in
08/2013 with Hartmann procedure with sigmoid colostomy.

POSTOPERATIVE DIAGNOSIS: Status post colon resection for cancer in
08/2013 with Hartmann procedure with sigmoid colostomy.

NAME OF PROCEDURE:
1. Colostomy takedown with colon resection and coloproctostomy.
2. Repair of enterotomy.
3. Take down of splenic flexure.

FINDINGS: We were able to take down the patient's colon. We
resected a small amount of the colostomy band and then affected a
coloproctostomy to his very short rectal stump using the EEA
stapler. He did have a lot of adhesions in the pelvis and in
taking some of the small bowel out of the pelvis we did have a
small enterotomy. We repaired this by basically doing a functional
end-to-end anastomosis with the stapler to repair the enterotomy.

DESCRIPTION OF PROCEDURE: The patient was placed on the table in
the supine posture after general anesthesia. The patient was
placed in lithotomy position. The Foley catheter was placed. The
abdomen and perineal area were prepped and draped including after
we suture closed the colostomy. A skin drape was placed. Skin
barrier drape was placed as well. We then entered through the
previous midline incision extending from the suprapubic area just
to the right of the umbilicus. We entered the abdomen without a
lot of difficulty. Fortunately not a lot of anterior adhesions
some omentum stuck anteriorly. We were able to enter the abdomen,
but going down into the pelvis he had very dense adhesions of the
small bowel to the sacrococcygeal area, but with patience we were
able to get the small bowel out of the pelvis with 1 small.
Enterotomy to repair this enterotomy we basically put the stapler
into the proximal and distal bowel and stapled, creating a
functional anastomosis and then stapled off the enterotomy to
close, thus repairing the enterotomy. Once this was all in order,
we then were able to remove the colostomy from the skin, making a
circular incision around the colostomy and then using the Bovie to
go to the subcutaneous tissue and fascia, freeing the colostomy.
At this point in time, then we could see that we seemed to have
adequate length to bring the bowel down into the pelvis,
particularly after we then took down the lateral peritoneal
reflection up to the splenic flexure, freeing up the colon even
more. We then placed a dilator _____ and saw that we of course
had a very short rectal stump, but we were prepared to do our
anastomosis. At this point in time, we then put the anvil of the
EEA through, we removed this suture and placed the anvil of the EEA
into the bowel through the colostomy and then pushed and then
stapled off the colostomy the bowel proximal to the colostomy
removing a small amount colon. It then seemed that we had adequate
length to come into the pelvis without difficulty. We therefore
went below and passed the stapler through the anus and created our
anastomosis with the EEA stapler. We had good doughnuts proximal
and distally and we did a leak test by filling the pelvis with
water and putting a clamp on the bowel proximally and then
insufflating the bowel with the rigid proctoscope and there was no
evidence of any leak. At this point in time, though on examining
the bowel there was a little posterior tension from some of the
scar. We then spent some time releasing the scar until there
appeared to be absolutely no tension on the anastomosis at all. It
was more tension on the mesentery than the bowel. The bowel
actually went down quite easily but there was a little tension on
the mesentery and we spent some time taking down the scar to ensure
that there was no tension on the mesentery as well. We then used
some of the hemostatic fabric and some Arista hemostatic powder to
ensure good hemostasis. We then took some omentum off the
transverse colon, so it would come down in the pelvis. We then put
some fibrin glue around the anastomosis and also packed the omentum
down into the pelvis. We then layered the small bowel back into
place on top of it. We then closed the fascia with PDS from the
colostomy incision both posteriorly and anteriorly and then closed
the skin of the colostomy incision over a 10 millimeter Jackson-
Pratt drain left in the subcutaneous. We then closed the midline
fascia with running PDS and closed the midline skin with surgical
clips as well. Dressings were applied. The patient tolerated the procedure well.


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## tcooper@tupelosurgery.com (Dec 16, 2014)

I think you could use the 44626. This code would cover the Colostomy Takedown with Resection of colon  and anastamosis. You could probably add a 22 modifier and send documentation. 
Hope this helps some.
Teresa Cooper, CGSC


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