# Exp Lap, Hemicolectomy, splenic flexure, Colostomy placement



## bill2doc (Oct 10, 2012)

Can anyone offer help with the CPT's for this.  Thank you so much in advance !

1.  Exploratory laparotomy.
2.  Left hemicolectomy.
3.  Takedown of the splenic flexure.
4.  Colostomy placement.

Generous midline incision was then made and carried through subcutaneous tissues to the fascia.  The superior aspect of this incision incorporated in an old ventral hernia mesh.  The fascia was then incised and the abdomen entered. There was significant amount of purulent fluid throughout the abdomen.  Initially, the plan was to attempt to avoid the upper midline mesh; however, the incision did need to be extended superiorly due to the size of the mass and the surrounding inflammation.  The mesh was then sharply incised.  Given the amount of purulent material, there was significant concern for the potential for infection in the mesh given that it was a foreign body.  The exposed areas of the mesh were then removed with a combination of sharp dissection and electrocautery.  Upon entry in the abdomen, in addition to the fluid which was evacuated, a large mass could be seen in the mid to distal transverse colon.  Initial evaluation noted a small area of necrosis and potential perforation along the superior mesenteric aspect.  The abdomen was examined.  No other lesions were found.  No concerning masses were noted or palpated in the liver.  Attention turned towards the colon.  The left pericolic ligament of Treitz was incised and the colon was reflected medially.  There was significant amount of inflammation and increase in adhesions at the splenic flexure which were slowly taken down.  The posterior aspect of this mass potentially involved the stomach and as the splenic flexure was mobilized an increase in the purulent fluid could be noted and there appeared to be a contained collection which was posterior to the stomach.  Swabs of this material were taken and sent for culture.  This posterior area was then opened and drained.  There was a second perforation noted over the posterior aspect of the colonic mass at this time and this mass did not appear to bodily invade the stomach; however, the inflammatory reaction of the surrounding tissue pulled the stomach into this mass and it was easily separated.  The points of transection for the left colon, one from the proximal aspect at the proximal transverse colon with a portion of the right colic available to feed the ascending colon at the distal point fossa.  The colon was then divided at these points using a linear cutting stapler.  The mesentery was then divided using the LigaSure device as well as suture ligatures for the larger vessels.  The colonic mass was completely mobilized and passed off the field as a specimen.  Given the amount of purulent fluid in the abdomen, it was thought imprudent to connect her at this time.  The abdomen was then copiously irrigated with sterile normal saline.  Attention then turned towards the formation of the stoma.  The stoma site was identified on the right side lateral to the umbilicus.  The site was grasped and elevated and a surgical incision was then made.  This incision was carried through the subcutaneous tissue to the fascia where a cruciate incision was made into the fascia and the abdomen could be entered from this portal.  It was stretched to the size of 2 finger width.  The remaining ascending colon was then brought up through this portal.  At this point, a full reevaluation of the abdomen was performed.  The small bowel was run from ligament of Treitz to the ileocecal valve.  The liver and spleen were identified and noted to be free of evidence of metastasis or infection.  The gallbladder was enlarged but did not appear inflamed.  The sigmoid colon did demonstrate multiple diverticula with no evidence of local inflammation.  The abdomen was then closed using a running looped 0 PDS.  The skin was stapled and dressings were then applied.  The midline incision was then protected.  The stapled end of the colon was then incised and passed off the field as part of the original specimen.  The colostomy was then matured using 3-0 Vicryl.  A stoma bag was then placed.


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## Michele Hannon (Oct 10, 2012)

44141


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## heathermc (Oct 11, 2012)

i would use 44143 and 44139


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## bill2doc (Oct 11, 2012)

I will look into all of these.... Thank you so much for pointing me in the right direction!


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## colorectal surgeon (Oct 13, 2012)

I would code this as 44143 (colectomy with colostomy).

I don't believe 44139 is billable here. You need to check the coding book as to which procedures 44139 can be added on. I don't think it is.

Don't forget to code for removal of the mesh. He does dictate in his note that he did it.  Look at 27087. 

He also states he drained an abscess and cultured it. 49020


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