# Mesorectal excision



## dmaguire (Aug 15, 2011)

I am trying to find the best code for this procedure.  I am leaning towards 45113 and wanted to know what othere's are thinking.

Operation:  Low Anterior resection, end-to-end anastomosis, total mesorectal excision, diverting loop ileostomy.

Procedure:
A midline incision was made.  The abdomen was entered.  There was a moderate amount of adhesions in the right lower quadrant at the site of the previous appendectomy.  There was a fair amount of induration in the irradiated rectum and a portion of the terminal ileum.  The adhesions in the region of the right lower quadrant were taken down.  The colon was mobilized. A site for transaction of the colon was selected at approximately the upper sigmoid.  The stapler, GIA-60, was fired across the colon.  The leaf of the mesentery on either side of the sigmoid and rectal mesentery was taken down.  The LigaSure device was used to come across the mesentery.  This was carried down to the beginning of the inferior mesenteric artery which was doubly clamped, cut, suture ligated, and tied off with #0 silk suture.  On either side, the ureter was identified and dissected free.  Both ureters were involved in radiation inflammation, and had some kinking that might have been mildly symptomatic for the patient.  Using blunt dissection and the LigaSure device, a total mesorectal excisionwas performed staying above the plane of the sympathetic and parasympathetic nerves, and just off the seminal vesicles anteriorly.  Going at least 5 cm beyond the tumor, the distal rectum was  isolated, and using the contor stapler, it was doubly stapled and transected.  The 25 mm EEA was used.  The anastomosis was fashioned in a side of the colon, a pursestring suture of 2-0 Prolene was placed, and the anvil was tied in.  The stapling instrument was passed into the rectum, the puncture device was fired just beneath the staple line in its middle, the anvil was connected, the 2 ends of bowel were brought together, and the stapler was fired per the manufacturer's guidelines.  Two intact donuts were identified and confirmed.  A rigid sigmoidoscopy was performed. The anastomsis was visualized and seemed to be patent, and the anastomosis was insufflated without any leakage of air.  There was no tension on the anastomisis.  Given the patient's poor nutrition, history of clostridium difficile, and preoperative chemoradiation therapy, it was determined that he was at high risk for anatomotic leak, so, a diverting ileostomy was performed in the right lower quadrant.  This was brought out through the rectus muscles.  The ostomy was opened but not matured.  Hemostatsis was assured.  The abdomen was thourghly irrigated.  Intercede was placed below the incision and all around the loop ileostomy.  A #1 Prolene was used to close the fascia in a running fashion.  The skin was closed with staples.  The stoma was covered with a bag.

Postoperative Diagnosis:  Rectal cancer having received preoperative chemotherapy and radiation therapy

Any insight or recommendation is welcomed.  Thank you in advance for taking time to look this over.

Danielle


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## colorectal surgeon (Aug 16, 2011)

44145 and 44310 is how I code it. some occasionally argue that 44146 should be used instead of both of these but this code states colostomy and an ileostomy was done instead


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