# drainage of presacral space



## SH1159 (Dec 18, 2014)

Help with CPT code please!

 DATE OF OPERATION/PROCEDURE: 10/28/2014 
PREOPERATIVE DIAGNOSES Colorectal anastomotic leak with presacral fluid collection proximal, stool found in colon. P
OSTOPERATIVE DIAGNOSES Colorectal anastomotic leak with presacral fluid collection proximal, stool found in colon. 
OPERATION/PROCEDURE PERFORMED Exam under anesthesia, drainage of presacral space, rigid proctoscopy with irrigation and aspiration of distal colon, placed a transanal presacral drain. OPERATIVE INDICATIONS OPERATIVE FINDINGS 1. Contained presacral abscess with purulence. 2. No-to-minimal stool found in distal colon. 3. 2-inch Penrose drain placed in the presacral space and sutured to the left anal margin with redundancy of the Penrose in the presacral space noted. OPERATIVE PROCEDURE IN DETAIL Patient was taken to the operating room, placed in supine position after induction of general anesthesia, LMA was inserted. He was placed in lithotomy position using candy-canes. Digital rectal exam was performed which revealed the posterior 40% to 50% circumference of the anastomosis about 3 cm above the dentate line to be disrupted. There was a presacral collection of purulence. This was irrigated and aspirated with no additional fluid encountered and anoscope was used to help visualize this anastomotic disruption for irrigation and aspiration. Rigid proctoscopy was then performed. The proximal colon was reached and minimal stool was seen. The distal colon was irrigated and aspirated with minimal effluent noted. The water was forced into the rectum by insufflating the proctoscope after water was inserted into the proctoscope itself. An anal tract was then placed. A 2-inch Penrose was placed in the presacral space. It was then trimmed at the anal margin. It was then sutured to the anal verge with 2-0 silk x2 after painting the area with Betadine. At this point, the procedure was terminated. The area was then washed and dried. A diaper was applied. The patient was then awoken from anesthesia. The LMA was removed. He was then taken to recovery room in stable condition having tolerated the procedure well. SPECIMENS SUBMITTED None.


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