# Laparoscopic assisted sigmoid colon resection



## Trendale

Hi,
I am not sure if these are the correct codes and modifier for the following surgery. Should there be a separate code for the dcompression of ovarian cyst? would the assistant surgery append 80 to his surgery only? I did not think the primary physician that is doing the main PX would get the 80. The codes I have is 44204 and 44213 w/o 80 ( he is the primary physician) Thanks for your help!

NAME OF OPERATION:
1 Laparoscopic-assisted sigmoid colon resection.
2 Take-down of splenic flexure and decompression of left ovarian cyst.
ANESTHESIA:  General anesthesia with intubation.
ESTIMATED BLOOD LOSS:  Approximately 100 cc.
GROSS OPERATIVE FINDINGS:  Upon entering the abdomen with the
laparoscope, we immediately noticed some diverticulosis of the sigmoid
colon.  In addition to that, there was a large cystic mass consistent
with a left ovarian cyst that was strongly adherent to the mid sigmoid
colon.  Both digital dissection as well as sharp dissection was used
to slowly separate this structure from the sigmoid colon.  The liver
was otherwise smooth with no discernible pathology.  There was no
other pathology found in the pelvis except for the one just mentioned.
DESCRIPTION OF OPERATION:  The patient was brought to the operating
room, positioned on the operating table in the lithotomy fashion.
After induction of anesthesia with intubation, the abdomen was prepped
and draped in the usual sterile fashion.  Marcaine 0.5% plain was now
used to infiltrate in the right upper quadrant subcostal midclavicular
line and a 5 mm port was placed through this incision.  Under direct
laparoscopic vision, we now placed a 12 mm port through a
supraumbilical incision and a second 12 mm port was now placed in the
right lower quadrant in the pelvis region.  Immediately, we switched
to the 30 degree 10 mm scope and, using the LigaSure, we began taking
down the attachment of the sigmoid colon, moving in a cephalad fashion
towards the spleen.  We first identified the white line of Toldt and
began remobilizing our colon, again moving to the level of the splenic
flexure.  We now began going down towards the area of the pelvis
region.  Immediately, we encountered this large complex structure
which appeared to be cystic in nature and what appeared to be a
arising from the left ovaries.  This structure likely represented a
very large ovarian cyst.  We identified the cyst and the cyst was now
decompressed at this point in time to make dissection easier to carry
out.  Using the LigaSure, we began separating the structure in the
left ovary away from the sigmoid colon.  Once we were able to separate
both structures, we were able to now lab retract it out of the way and
continue mobilizing our sigmoid colon to the level of proximal rectum.
We now placed a Gelport through a Pfannenstiel incision and turned
the case to laparoscopic-assisted by placing my hand and I was able to
now continued mobilizing the sigmoid colon again to the level of the
proximal rectum.  We now concentrated in going upwards and taking down
our splenic flexure.  Both digital blunt dissection as well as sharp
dissection with the LigaSure was used to take the attachment of the
colon to the area of the spleen so that we can mobilize it well and
bring it all the way down to the pelvis and do an appropriate
resection and anastomosis.
Once we had mobilized the transverse, descending and sigmoid colon to
satisfaction, we now went to the level of the proximal rectum at the
level of the sacral promontory and we made a small hole on the
mesentery of the distal sigmoid and proximal rectum area.  We now used
a 3.5 reticulator and the GIA positioned across it, closed and fired.
We now began taking down the mesentery of blood supply using the
LigaSure as we moved towards the spleen.  Once we have taken down the
mesentery, we were now able to bring now the entire specimen pretty
much through our Gelport at which point we placed a bowel clamp across
it, cut the specimen by the mid descending colon and passed the
sigmoid over the table as a specimen.  We now used our sizers and
chose appropriate size EEA.  The anvil was placed into the proximal
colon and a reload on the 3.5 Endo-GIA was now used and positioned
across the end of the colon, closed, and fired.  The anvil was brought
out proximal to our staple line.  My assistant now went down to the
area of the pelvis.  He dilated the anus and rectum and brought in the
shaft of the 28 EEA.  We positioned it on the rectal stump, opened it,
brought it together with the anvil, closed, and fired, creating our
end-to-end anastomosis.  We now tested anastomosis on the air while
under saline to make sure there were no leaks.  There were no leaks
identified and no defect, but the area was then reinforced with
seromuscular layer of 2-0 silk.
At this time, the abdomen and pelvis were irrigated and, upon
irrigation, closure was performed.  Closure of the fascia defect by
the Gelport was done with a running 1 PDS.  Then the skin incision was
done with 4-0 Monocryl in a subcuticular fashion.  Port sites were
closed also with 4-0 Monocryl in subcuticular fashion, followed by
Benzoin and Steri-Strips.  Patient tolerated procedure quite well.
She was then taken to recovery in stable condition.


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## mjewett

" We now placed a Gelport through a Pfannenstiel incision and turned
the case to laparoscopic-assisted by placing my hand and I was able to
now continued mobilizing" 

I pulled the above sentence from the operation report that you posted. I think the word "assisted" is referring to the technique, not that there was an assistant surgeon. 

The procedure was performed laparoscopic, but the incision is widened to allow a laparoscopic hand port to be place. The surgeon is then able to insert his/her hand into the "belly".  My surgeon calls this technique laparoscopic hand assisted, __________.  For coding purposes it is still considered laparoscopic, therefore code 44204 is correct. I would also consider billing 58662.

Hope this helped-


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