# Laparoscopic sigmoid colectomy converted to open with 2 small bowel resections



## bill2doc (Dec 31, 2012)

Can anyone offer CPT help please ????

DESCRIPTION OF PROCEDURE:  Patient was then placed in a modified lithotomy position.  A digital rectal exam was performed and no masses or lesions were noted. A rigid proctosigmoidoscopy was performed and there were no lesions visualized.  The abdomen was then prepped and draped in a standard fashion.  A midline supraumbilical incision was then made, carried through subcutaneous tissues to the fascia at the base of the umbilicus which was then subsequently divided.  A heavy Vicryl was placed on either side of the fascial defect and a Hasson trocar was then entered in the abdomen.  Pneumoperitoneum was established.  Immediate evaluation of the abdomen noted no evidence of injury secondary to port placement.  Examination of the abdomen noted an adherent inflammatory mass in the midline in the suprapubic region.  Two 5-mm ports were placed through separate stab incisions under direct vision, one in the left lower quadrant and one in the right lower quadrant.  Using these ports, there was a gentle blunt dissection to free this inflammatory mass and determine exactly its nature.  During this blunt dissection, there was evidence of spillage of pus which was evacuated with the suction irrigator.  A third 5-mm port was placed in the right upper quadrant and some of the mass was able to be dissected from the surrounding tissues, but given the level of this inflammation and amount of pus present, it was determined that it would be much safer to approach this from an open position as there was no way to determine whether the mass was involving the colon or the small bowel and whether there was any sort of fistulization from one to either of these two systems.  A midline incision was then made and carried through subcutaneous tissues to the fascia.  At this point, the inflamed area was able to be visualized.  There were multiple loops of small bowel that were adherent to this inflammatory mass, which did involve the sigmoid colon as well.  This was adhesed to the anterior abdominal wall but did not appear to involve the bladder.  This was then dissected from the abdominal incision and then the loops of bowel was dissected from the colon.  There was minimal spillage of residual pus through this maneuver.  Once these maneuvers were completed, they will be further examined.  The source of the inflammation appeared to be the mid distal sigmoid colon and there were to loops of small bowel, one that was approximately 20 to 30 cm from the ileocecal valve and a second one that was in the distal jejunum that had formed a wall off of the inflammation in that area.  The small bowel was then packed away for further evaluation at the end of the case and the abdomen was then irrigated with warm sterile normal saline to allow for visualization.  There were no other areas of acutely inflamed diverticula noted.  The colon was then mobilized in a lateral to medial fashion by initially incising the white line of Toldt and dissecting the lateral attachments of the colon and the posterior aspect of the mesentery from the abdominal wall.  The dissection was then carried down towards the proximal rectum.  The left ureter was identified and protected.  Once the colon had been completely mobilized, the mesentery was then incised.  The proximal and distal points of transection of the colon were then identified.  The colon was then divided with a linear cutting stapler.  The mesentery was then divided with a LigaSure device.  The dissection was continued to the superior aspect of the rectum.  The mesorectum was then dissected and the anterior and lateral attachments of the rectum were then divided to allow for further distal mobilization.  The proximal mesorectum was then dissected from the bowel, which was then divided with a contour cutting stapler.  The sigmoid colon was then passed off the field as specimen.  The colon was then allowed to rest into the pelvis and it appeared that there was enough length to be mobilized so that a tension-free anastomosis could be performed.  The proximal colon was debrided of its epiploic fat along the staple line and a pursestring device was then used to place a pursestring suture in place.  The rectum was incised and a 31 mm EEA stapler was then brought out.  The anvil was then placed in the proximal colon and secured with the pursestring suture.  The EEA was then guided through the anus and into the rectum.  The anvil was brought down into the pelvis and connected to the EEA stapler.  The colon was then examined and determined that there was no tension and the stapler was then closed and fired.  The stapler was then removed and the donuts were examined.
Two doughnuts were verified.  The colon was then clamped and the proctoscope was then entered into the rectum and insufflated well.  The colon was cleansed with warm sterile normal saline and there was no air bubbling identified.  The small bowel was again examined and the 2 loops of bowel, which had been indurated and firm, did not appear to be significantly better on further examination and there were multiple areas of serosal tears and a significant amount of inflammation concerning for potential narrowing and later strictures.  An incision was then made to resect each of these segments.  The proximal and distal points of resection were then identified.  The mesentery between those points were then divided using the LigaSure device.  A linear cutting stapler was then used to form the anastomosis and then the specimen was resected with a second look.  The mesenteric defect was then closed using a running 3-0 Vicryl suture and any bleeding along the staple line was stopped using a suture ligature of 3-0 silk.  Each of the 2 small segments were resected individually in the same fashion.  The bowel was then allowed to return to the abdomen and the entire abdomen was again copiously irrigated with warm sterile normal saline.  Hemostasis was assured.  The midline incision was then closed using a running looped #1 PDS.  The port sites were closed with staples as was the skin of the midline incision and dressings were then applied.  The patient was allowed to awaken from anesthesia and brought to Recovery Room in good condition.


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## SUE TROXTELL (Dec 31, 2012)

please view 44145


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