# Subtotal colectomy/small bowel resection



## ksb0211 (Aug 4, 2011)

I just want to make sure that I'm not missing anything.  For some reason, these types of surgeries always may me nervous.  LOL
I am greatly appreciative of any input...Thanks.

PREOPERATIVE DIAGNOSIS
Small bowel obstruction, mass left upper quadrant.

POSTOPERATIVE DIAGNOSIS
Small bowel obstruction at ligament of Treitz with mass which appears to be tumor and evidence of small bowel perforation at that level with involvement of transverse colon.

OPERATION PERFORMED
1. Exploratory laparotomy.
2. Subtotal colectomy.
3. Small bowel resection with entero duodenal anastomosis.

ESTIMATED BLOOD LOSS
Perhaps 150 cc's.

PROCEDURE
The patient was taken to the OR. After induction of general anesthesia the patient was prepped with DuraPrep and draped sterilely. After antibiotics had been administered the incision was made with a #15 blade in the midline centered on the umbilicus. Ultimately the incision was lengthened significantly to allow this exploration. The patient had a large mass which was noted to be firmly attached to the transverse colon emanating from the region of the ligament of Treitz. The first portion of the small bowel just at the ligament of Treitz was going through the region of the tumor. This caused a small bowel obstruction. There was evidence of previous right colectomy. The dissection was begun initially over the mass reflecting the omentum off of the transverse colon. The transverse colon was markedly adherent to this mass which emanated from the region of ligament of Treitz involving much of the mesentery in that area. The splenic flexure was mobilized and taken down. Once I was able to do this I was able to get above the lesion and dissect down towards the ligament of Treitz. It was clear that the large bowel was completely involved with this lesion. It was also clear that this involved mesentery and was close to superior mesenteric vasculature. The right colon was then mobilized. There was scarring from the previous surgery but the ileocolic anastomosis was found and carefully freed. Dissection was continued medially towards the duodenum. Once this was completed the decision was resection would be necessary. A GIA was passed at the region of the ileocolic anastomosis. The colon was then divided distal to the splenic flexure. Then the mesentery was taken down utilizing the Harmonic scalpel and suture ligatures of 3-0 and 2-0 silk. The tumor appeared to be on the superior mesenteric vessels. It was thought not to be possible to fully resect it. A plane was developed and we actually moved through a section of cavitary portion of the tumor utilizing the Harmonic scalpel. Hemostasis was achieved. Once this was done the colon could be passed off as specimen. What remained was the obstruction of the small bowel at the ligament of Treitz. The small bowel was  then divided just distal to the point of obstruction and then it was carefully dissected free from the tumor. It became clear that the pathology also involved a disruption of the small bowel and I believe this is the etiology for the mass and cystic cavity associated with the tumor. The section of small bowel was then resected. The duodenum was divided with a GIA stapling device right at the ligament of Treitz. Once this was completed and the section of affected small bowel removed an anastomosis was performed utilizing the GIA stapling device. The enterotomy was closed with 3-0 Vicryl and interrupted 3-0 silk canal sutures. The abdomen was thoroughly irrigated with antibiotic solution. What remained then was the ileo rectal anastomosis. The distal sigmoid was compromised so that an additional resection of sigmoid colon left the most distal sigmoid and rectum. The small bowel to colon anastomosis was then performed utilizing the GI stapling device. The enterotomy was closed with a TA 60 with green staples. The wound was again irrigated. A 10 mm Jackson Pratt drain was placed via separate stab incision. The midline incision was closed with running double stranded #1 PDS suture. NG tube placement was confirmed. There was no other evidence of metastatic disease though the local disease was still significant.
The patient was taken to the recovery room and intensive care unit in guarded condition.


----------



## mstallings (Aug 4, 2011)

Hi- looks like the surgeon did a partial colectomy (44140), moblization of splenic flexure (44139), small bowel resection (44120) and an additional separate resection (44121). Hope this helps.


----------



## theresadickson (Jun 17, 2014)

so in this instance would you put a modifer 51 or 59 on the small bowel resection.  I keep getting them denied by novitas when I pair with a colon resection and I am not sure why!


----------

