# Total Proctocolectomy With ileoanal J-pouch And Diverting Loop Ileostomy



## hcg (Feb 13, 2013)

I was thinking of CPT 44158 & 44157 ( per code correct this code is mutually exclusive to code 441458 and cannot be billed using a modifier), but I am not sure if this is the right code. Can anybody please help me on this?


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PREOPERATIVE DIAGNOSIS: Ulcerative colitis, failed medical therapy.
POSTOPERATIVE DIAGNOSIS: Ulcerative colitis, failed medical therapy.
SURGEON: Dr. A
ASSISTANT: Dr. B
ANESTHESIOLOGIST:
ANESTHESIA: General.
OPERATION: Total proctocolectomy with ileoanal J-pouch anastomosis and diverting loop ileostomy.

ESTIMATED BLOOD LOSS
100 mL

INDICATIONS
The patient is 22-year-old  with a history of ulcerative colitis. She has failed medical therapy, including immuno-modulators and anti-inflammatories. She has been having ongoing rectal bleeding. I was asked to see the patient and I offered total proctocolectomy. The options of ileoanal J-pouch anastomosis versus permanent ileostomy were reviewed with the patient and her questions were answered.

DESCRIPTION OF PROCEDURE
The patient was identified having undergone a mechanical and antibiotic bowel prep. She was brought to the operating room and placed in the supine position. General endotracheal anesthesia was administered. The patient was then placed into a modified lithotomy position with appropriate padding to all pressure points. Digital rectal examination confirmed good sphincter tone, proctoscopy to a distance of 15 cm confirmed fragile bleeding mucosa. The rectum was irrigated with Betadine solution.

The abdomen was prepped with ChloraPrep and appropriately draped. Midline laparotomy incision was made from the pubic symphysis to the umbilicus. Subcutaneous dissection was performed. Rectus fascia was incised in the midline. Sharp dissection was used to enter the peritoneal cavity. Bookwalter retractor was utilized. The colon looked moderately ill as expected.  There was no evidence of toxic colitis. The stomach and small bowel were normal. The liver was palpably normal. The gallbladder was also normal.

The Bookwalter retractor was used for exposure. I started by taking down the splenic flexure. I started at the descending colon incising the lateral retroperitoneal attachments at the white line of Toldt. I did so using sharp dissection and the harmonic scalpel. I continued my dissection around the splenic flexure, elevating the omentum from the transverse colon and mobilizing the splenic flexure by incising its avascular attachments with the harmonic scalpel. Continuing my dissection to the midline and into the right upper quadrant, continued mobilization of the transverse colon, the hepatic flexure proved to be technically challenging to mobilize because of the redundancy of the colon underneath the liver, but ultimately I was able to mobilize the colon safely without injury to the liver or the duodenum. The avascular attachments of the ileum were also released.

I then turned my attention to the pelvis. I mobilized the sigmoid colon out of its lateral retroperitoneal attachments by incising the white line of Toldt. I was able to identify the left and right ureters and preserve them. I continued my dissection down into the pelvis taking down the peritoneum and creating a circumferential dissection around the rectum elevating a bladder flap anteriorly and taking the rectum off the overlying uterus,  cervix and vagina. I continued my dissection. I took down the lateral rectal stalks using the harmonic scalpel. I continued down onto the pelvic floor.

Digital rectal examination confirmed that I had done my dissection down to just about 2 cm above the anal verge, I thought that this was sufficient. The curved universal stapling device with the purple load was then used to transect the rectum just above the anal sphincter muscles. The rectum was then elevated up into the wound. I then transected the terminal ileum using the universal stapling device and a blue load. I took down the terminal branches of the ileocolic vessels with white loads the stapling device. I took the right colic and the middle colic vessels also with a stapling device. I took the left and sigmoidal vessels as well completely mobilizing the colon and removing it from the field and sent for pathologic evaluation.

Inspection revealed no evidence of ongoing bleeding. I then identified the terminal ileum. I mobilized some avascular attachments, so that I could  easily mobilize the ileum down into the pelvis.  I created a J-loop with a length of 15 cm and created an enterotomy at the apex of my J loop and through this enterotomy, I passed the Universal stapling device and a blue load. I created a linear side-to-side J-pouch double barrel in configuration for the entire length of 15 cm. Once the pouch was properly created and there was good hemostasis, I placed a 28 mm EEA anvil into the previous enterotomy and secured it in place with a pursestring of 2-0 Prolene.

Dr. B then went to the pelvis serially dilating the anus. He passed a 28 mm EEA stapler up to the anus and onto the rectal staple line. The spike was extruded. The spike and anvil were married and an ileoanal anastomosis was created. Inspection confirmed good anastomosis. The donuts were intact. Rigid proctoscopy with occlusion of the pouch confirmed good dilation without evidence of leak or bleed. The abdomen was irrigated with saline until the effluent was clear. Sponge, instrument counts were reported as correct. A disk of skin was then excised from the right lower quadrant, as well as the underlying cylinder of fatty tissue. The anterior rectus sheath was incised in a cruciate fashion. The posterior rectus sheath was incised vertically to a diameter of about 2 fingerbreadths.

I identified a loop of small bowel proximal to the ileoanal pouch such that I could deliver easily to the anterior abdominal wall and without significant tension, I encircled this loop of bowel with a 14-French red rubber catheter. The small bowel was delivered onto the anterior abdominal wall without difficulties. The rectus fascia was re-approximated with continuous 0 loop PDS. The wound was irrigated with saline and the skin was closed with staples. It should be noted that the patient had supraumbilical piercing and I had to excise this skin to facilitate closure of the wound. The ileostomy was matured in a Brooke-type fashion using 4-0 Vicryl sutures. Full thickness bites of the skin, deep bite of serosa and full thickness mucosa were created at the cardinal points. The red rubber catheter was left in place as a bridge to help to keep the ileostomy elevated.

Lastly, an 18-French red rubber catheter was sewn into the ileal pouch to allow for continuous drainage with a single 2-0 silk suture. Dry dressings were applied, and an appropriate appliance was applied and the procedure was terminated. The patient tolerated the procedure well without complication.


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## cynthiabrown (Feb 15, 2013)

look at 45119


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## hcg (Feb 15, 2013)

cynthiabrown said:


> look at 45119




I look at the code & it is better than what I got. Thank you so much. I appreciate your help


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## cynthiabrown (Feb 15, 2013)

glad to help


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