# Laparoscopic Cecectomy



## NorthstarCoder

What CPT code should I use for a laparoscopic cecectomy for the removal of a lesion/polyps? Our office had originally chosen 44110 until we noticed that it was for an open procedure.


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## MEZIESKY

*Me Too*

I was looking for the same thing. Hope some one out there can help.

mgrubb


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## MEZIESKY

After I read the op report for the one I needed for the lap cecectomy I used the 44204.


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## cmartin

Laparoscopic cecectomy would usually be a 44205, since the cecum connects the colon to the terminal ileum.
C.Martin CPC-GENSG


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## mjewett

I agree to using code 44205.


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## sabrinaecob@gmail.com

*Help!!*

PROCEDURE PERFORMED:
1.  Second look laparoscopy for ovarian cancer with collection of peritoneal 
cytology and removal of peritoneal implants and partial omentectomy.
2.  Laparoscopic cholecystectomy with intraoperative cholangiogram.
3.  Ileal colostomy with partial colectomy and resection of terminal ileum.

SPECIMENS: Peritoneal implants.  Peritoneal cytology.  Gallbladder and its 
contents.  Portion of terminal ileum.  Portion of colon.  Portion of omentum.

INDICATIONS: The patient  female who has history of ovarian 
cancer.  She has undergone a radical hysterectomy with debulking, also a 
rectosigmoid resection and right hemicolectomy.  She is here for reversal of 
colostomy, second look laparoscopy and cholecystectomy.

DESCRIPTION: After informed consent was obtained, preoperative antibiotics, as
 well as subcutaneous heparin were administered within the hour of the 
procedure per protocol.  .  General endotracheal anesthetic was 
applied.  Sequential compression devices were in place and functioning at time
 of induction.  All pressure points were padded.  A surgical time-out was 
performed per CMS guidelines.  Her abdomen was prepped and draped in normal 
sterile fashion with the Op-Site covering her ileostomy.

Initially a Veress needle was placed in the left upper quadrant.  A 2 liter 
pneumoperitoneum was created and a 5 mm trocar was then inserted.  Inspection
 of the abdomen showed an endoileostomy with a small hernia around the stoma,
 or a parastomal hernia and multiple implants throughout the abdomen.  A 12 mm
 port and 2 right subcostal 5 mm ports were placed.  Attention was initially 
directed towards collection of the specimens.  Multiple small little nodules 
were noted throughout the stomach, the gastrohepatic ligament, as well as the
 bed of the gallbladder.  The liver was otherwise unremarkable.  There was 
evidence of a long mucus fistula with the hepatic flexure to the descending 
colon remaining intact.  There was no pelvic lesions.  As many implants as 
could be submitted were submitted, some for frozen and some for permanent and
 all the initial pathology returned negative for malignancy.

The abdomen was filled with a liter of saline.  There was a 5 minute dwell 
time and then the fluid was aspirated and sent for cytology.  Upon completion
 of this the gallbladder was taken down in a dome down fashion until I got to
 the level of the cystic artery.  It was doubly clipped and divided.  The 
cystic duct was skeletonized.  The duct itself was approximately 4 cm in 
length.  It was cannulated with a cholangiogram catheter and under 
fluoroscopic interrogation there was sluggish flow through a mildly dilated 
common bile duct, but it eventually went into the duodenum without difficulty.
  The proximal biliary radicles were nondilated and there was no evidence of 
strictures or other lesions, or any filling defects within the common bile or
 common hepatic duct.

With that in mind the cholangiogram catheters were removed, 2 clips were 
placed on the cystic duct stump.  Bovie cautery was applied delicately to the
 end of the cystic duct to prevent postoperative leakage.  The gallbladder bed
 was inspected and was hemostatic.  The gallbladder was then placed in the 
left upper quadrant for later retrieval.

This being done, the 12 mm port was closed at the fascial layer using #0 
Vicryl suture.  I then cored out the ileostomy down to the level of the 
fascia.  I mobilized the entire remaining right colon off of the duodenum and
 off Gerota's fascia taking care to prevent ureteral or vascular injury.  
After having satisfactory length, I then mobilized the entire ileostomy.  I 
pulled the ileostomy out through the ileostomy incision and freshened up the 
end resecting approximately 3 mm of terminal ileum.  I then pulled up the 
colon through the same incision and repeated the procedure.  I removed the 
gallbladder through the incision where the ileostomy was, passed this off the
 field.  I then created an end-to-end functional side-to-side anastomosis, 
placing GI pop-off silk sutures on the intermesenteric portions of the small 
bowel and the colon after ensuring there was no twist in the bowel.

With this being done, I then opened the colon and small bowel, placed an 
endo-GIA 6 mm white load, advanced it, locked and fired it, creating a linear
 stapled ileocolostomy.  Three GI pop-off silks were then used to temporarily
 close the common enterotomy and this was then closed with the stapling 
device.  The mesenteric defect was likewise closed with a series of 
interrupted silk sutures.  I then placed the entire anastomosis into the 
peritoneal cavity and closed the fascia with a looped #1 PDS suture tied upon
 itself.  Having completed this, all wounds were copiously irrigated with 
saline and then Betadine.  The fascia sutures at the 12 mm port site were 
closed.  The skin incisions were again copiously irrigated with saline and 
Betadine.  The ileostomy site was loosely reapproximated with a stapling 
device with Telfa placed as wicks and the laparoscopic sites were closed with
 4-0 Vicryl.  Mastisol, Steri-Strips and planes were then applied.  She was 
then awoken from anesthesia, extubated and transferred to the recovery room in
 stable condition, having tolerated the procedure quite nicely.


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## Torilinne

Am I wrong or did this patient have a previous ileostomy and the surgeon now reversed it?  I see a resection and anastomosis with closure of the skin level ileostomy site.  If this is the case, I'd look at 44227.  Other thoughts?

Torilinne
CPC, CGIC


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