# interesting op note :/



## herrera4 (Jul 12, 2011)

FINDINGS:  An approximately 10 inch x 1 1/2 inch wooden dowel covered in plastic was extracted from the midsigmoid colon transanally through laparotomy.  No perforation was found.  Bleeding was not visible through sigmoidoscopy performed x2 by Dr. A nor by flexible colonoscopy performed by Dr.A  Rigid sigmoidoscopy performed by Dr. B x1 was also unsuccessful in localizing the bleed beyond noting that it was between 8 to 12 cm.  An anterior colotomy above the rectosigmoid junction also failed to show the exact site of bleeding.  Ultimately the bleeding was found through anoscopy with additional manual retraction and the bleeding points were found to be tears at the 10 o'clock position and at the 12 o'clock position with the patient in lithotomy.  These were oversewn to stop the bleeding.
 TECHNIQUE:  The patient was placed in lithotomy position under general anesthesia.  T.E.D. hose were placed as were SCD hose, and the patient had received 2 gm of cefoxitin, 600 mg of Clindamycin prior to incision.  A lower midline incision was created and the colon was observed.  We inspected carefully for perforation.  None was found.  Blood was found to have refluxed all the way back to the small bowel.  I was able to move the foreign body down into the rectum with traction on the plastic bag hanging from the anus.  Ultimately with transabdominal approach, I was able to deliver the foreign body.  A large amount of blood was then expressed through a rigid sigmoidoscope with suction for control in prevention of contamination.  Approximately a liter of bloody effluent was taken out.  I then repeated rigid sigmoidoscopy to attempt to find the bleeding site, and I was unable to and so the blood kept welling up from the midrectal region.  Despite attempts at rigid sigmoidoscopy, I continued to be unable to identify the bleeding site.  I then switched to a flexible colonoscopy in hopes of being able to find the bleeding site.  Colonoscopy was performed from distal descending colon down to the rectal vault.  No lesions were found though blood obscured from around 12 cm distally and again I could not find the bleeding site.  I again redraped, prepped and exposed the anterior rectosigmoid junction.  A colotomy was made in the anterior wall along the tinea.  Using ribbon retractors, I attempted to find the bleeding site again, could not find anything other than it being in the mid to low rectum as the source.  The colotomy was closed.  At this point Dr. Blancaflor was able to assist me with rigid sigmoidoscopy while I maintained control above and again the bleeding site was not able to be found.  Surgicel was placed to help control things.  Dr. B and I as well as the P.A. then placed transanal retraction to visualize the lower rectum.  We were able to identify two linear tears in the anterior and anterolateral rectal vault.  These were seen to be bleeding.  I then oversewed the deeper lesion with 0 silk through the EndoStitch device transanally and the 12 o'clock position was oversewn with the running 2-0 Polysorb.  Hemostasis appeared complete.  Again we redraped and regowned and gloved.  The P.A. and I then reinforced the colotomy closure.  I had originally closed the colotomy with a running 3-0 PDS.  Due to the traction placed during the right sigmoidoscopy, I was concerned that there may be some suture pull.  Therefore a second layer was placed of interrupted 3-0 silk and additionally reinforced with 4 mL of Tisseel.  Hemostasis was confirmed and the sponges were confirmed to be removed from the abdomen.  Sponge counts and needle counts were correct initially.  We then did a running loop PDS closure of the midline fascia.  The umbilicus was then re-pexed to fascia with a 3-0 Vicryl.  The skin was closed with staples.  Sterile dressing was applied.  Sponge counts, needle counts and instrument counts were correct again on two additional counts, and the patient was transferred to recovery in stable condition though still intubated.  The patient did ultimately receive intraoperatively six units of red cells in addition of two units of red cells preoperatively and four units of FFP as well as two units received preoperatively.


Im originally thought 44604 but that was denied  any help is appreciated Thanks


----------



## colorectal surgeon (Jul 12, 2011)

44025   Colotomy, for exploration, biopsy(s), or foreign body removal (he explored for the bleeding site)

45330   Flexible sigmoidoscopy

45915  Removal of fecal impaction or foreign body (separate procedure) under anesthesia

I would resubmit 44604 as I think that's exactly what he did - suture of large intestine (rectum) for injury (from the foreign body)


----------



## surgonc87 (Jul 13, 2011)

OH my....They looked too far :/


----------



## herrera4 (Jul 13, 2011)

yes...yes they did thank you very much for the help


----------

