# Sigmoid Colectomy with bladder repair????



## surgerycoder (Feb 20, 2015)

Any and all help will be greatly appreciated.
The doc thinks 44143 and 44661.  A fellow coder states just 44143, while another states just 44661.

Preoperative Diagnosis: 
Perforated viscus and peritonitis

Postoperative Diagnoses:
1. Perforated diverticulitis with rupture into the bladder
2. Multiple interloop abscesses
3. Purulent peritonitis

Procedure Performed:
1. Sigmoid colectomy with colostomy, Hartmann?s procedure
2. Primary repair of the bladder

Specimen:
1. Peritoneal cultures sent for gram stain and culture.
2. Sigmoid colon

Findings:
Segmental diverticulitis with perforation into the bladder.

Description of Procedure:
??A vertical midline incision was made from the epigastrium to just above the pubis.  This incision was later extended superiorly toward the xiphoid for full exposure.  This was deepened through the subcutaneous tissues and hemostasis was achieved with electrocautery.  The linea alba was identified and incised and the peritoneal cavity entered.  The abdomen was explored.  There was purulent peritonitis evident with murky fluid and pus throughout all 4 quadrants of the abdomen.  The transverse colon and omentum were elevated cephelad.  The small intestine was run from the ligament of Trietz to the terminal ileum.  Multiple interloop abscesses were found.  The proximal jejunum down to mid ileum was noted to be dilated and full of fluid.  The interloop abscesses were opened and the pus was cultured and suctioned.  The bowel appeared to be viable.  Next, the right lower quadrant was explored and the cecum was identified along with the appendix.  The appendix appeared normal.  Next, the colon was followed up to the ascending and transverse colon.  The transverse colon and omentum were pulled caudal and the stomach was palpated.  The NG tube was noted to be in the lumen of the stomach and was adjusted into the duodenum for small bowel decompression after the duodenum was full inspected and noted to be without pathology.  Next, the transverse colon was lifted cephalad and the descending colon and sigmoid were inspected.  There was noted to be diverticular disease with portion of the sigmoid colon stuck up to the bladder.  This was bluntly taken down.  Using electrocautery, the colon was freed from its peritoneal attachments along the line of Toldt proximally from the splenic flexure and distally to the pelvic inlet.  The diseased segment of the colon appeared to be located in the sigmoid only.  The 2 points of sigmoid colon transected were chosen and dived with a stapler.  The proximal sigmoid was divided first with a GIA stapler with the blue load.  The Harmonic saw used to coagulate and transect through the mesentery adjacent to the sigmoid colon taking the right colic artery with it.  Dissection continued down into the pelvis as low as possible to reach non-diseased rectum.  A contour stapler with a black load was used to transect through the distal colon leaving a viable Hartmann pouch.  The specimen was passed off to pathology.  Next a site in the left lower quadrant was chosen to pull up a colostomy.  The proximal colon reached easily to the proposed colostomy site without tension.  A disk of skin and subcutaneous tissue was removed for the colostomy site in the left lower quadrant.  The incision was deepened through all layers of the abdominal wall and dilated to admit 2 to 3 fingers.  The colon was passed through the ostomy site without torsion or tension.  The abdomen was then copiously irrigated with 3 liters of warm saline solution and suctioned appropriately.  Prior to closing the abdomen the area in which the colon was stuck up to the bladder was locally explored and found to have feculent material inside the bladder wall.  This was debrided full thickness of the bladder wall and irrigated and suctioned.  The dome of the bladder was then closed with sutures in multiple horizontal mattress fashion.  The Foley was palpated to ensure the bulb was in good condition.  Next the colostomy was matured by removing the staple line and placing sutures to the deep dermis.  The skin was washed and an appropriate colostomy bag was fashioned.


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## cynthiabrown (Feb 20, 2015)

44661 would not include a colostomy. 44143 does as all colon resections do, include closure of fistula. cms policy manual  I believe chapter 9 or 12. I could send it to you if I had your email address


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