# Lap coloanal resection w/ divertying loop ileostomy & takedown of splenic flexure



## nlbarnes (Aug 21, 2015)

Hi- I need opinions please!  I'm thinking _maybe 45397-52_?  No 44213 if 45397 is used.  *I removed parts of this report since it was so long & highlight what I think were the qualifying parts of the report.  I'm hoping this will entice someone to help me please!!!    

*The surgeon had this to say:

This is a straight coloanal anastamosis, not a Jpouch, otherwise the procedure is correct.  I used the new code you gave me 245499 but then saw that it says Jpouch not just the coloanal straight anastomosis, perhaps this does not matter as for instance a total colectomy whether it is with an ileostomy or with an ileorectal anastomosis bills the same.  I also did take down the splenic flexure.  This may be included, can't recall so included that code.  I used to use 44207 and 44187 but this anastamosis is very low, to the top of the anal canal so not just your typical low anterior resection.

DESCRIPTION OF PROCEDURE: 
 Under direct vision, a #5 trocar was placed in the 
right upper quadrant and right mid quadrant, a #12 trocar in the right 
lower quadrant, a #5 trocar in the left mid quadrant.  There was no 
evidence of liver metastases or peritoneal carcinomatosis.  The ink 
could be visualized at a very deep pelvic reflection.  The white line 
of Toldt on the patient's left side was taken down, and then the left 
ureter was identified and preserved.  The #5 EnSeal and the scissors 
without cautery were used for the entire intracorporeal portion of the 
dissection.  The splenic flexure was taken down, taking care to avoid 
injury to the spleen.  We then opened the peritoneum of the mesentery 
at the base of the sigmoid colon and entered the presacral space.  The 
sympathetic nerves were not able to be visualized, but I believe I 
laid them posteriorly to my dissection.  The patient does have a 
fairly thick fatty mesentery both to his colon and actually to his 
small bowel as well.  The plane beneath the superior rectal artery was 
opened, and we joined the left-sided dissection and then we dissected 
up to the inferior mesenteric artery where it took off from the aorta 
and then opened the hole in the mesentery just proximal to the 
inferior mesenteric artery and then divided the inferior mesenteric 
artery at its base taking care to avoid injury to the left ureter. 
Using an Endo-GIA 60 white 2.5 mm stapler, the staple line was 
reinforced as per my habit with large hemoclips.  We then began to 
dissect down the presacral space.  This patient's pelvis was notable 
for being quite narrow and he had a heavy fatty rectal mesentery.  We 
placed a hand GelPort through a small lower midline incision, and with 
a combination of techniques, we eventually were able to complete the total mesorectal excision all the way down to the levators which we 
clearly visualized.  We could palpate the coccyx posteriorly and I 
could actually feel the entire prostate anteriorly as far as the 
anterior dissection.  Notably, I felt that the anterior plane was 
notable for all the organs being very tightly together.  I dissected immediately adjacent to the anterior rectum and I could actually see 
the seminal vesicles, meaning that there was essentially minimal space 
between the structures in this patient's pelvis.  Both ureters were 
again identified and preserved in the pelvis as well.  We then 
completed the total mesorectal excision, and I could palpate the 
rectum beyond the rectal mesentery; however, the patient's pelvis was 
so narrow I really could not find a way to actually see this spot 
using the laparoscope or even open using a St. Marks as the patient's 
pelvis was also quite long.  I contemplated what to do at this point. 
Clearly, I would not be able to put on laparoscopic staplers without 
some ability to visualize at least the starting corner where I wanted 
to work, so instead I opened the hand GelPort and I took a green 
contour stapler and placed it in the pelvis and then I could barely 
fit my hand in next to the contour stapler, and then manually using 
palpation only, I rolled the distal rectum into the stapler, put the 
pin down, and then I used the suction to push the tissue away on 
either side, so I could be sure I had not caught any sidewall tissue 
in the stapler, which I had not, and then by palpation, I could 
palpate that I was down enough to be right at the level of the 
levators which would of course be just passed by total mesorectal excision.  I went ahead and closed the stapler at this point.  I 
checked through the anus the distance up and that also seemed 
appropriate by using another glove and doing a rectal exam.  I then 
removed that glove and then fired the stapler.  When I pulled the 
specimen up and out of the abdomen, I could see that I had a single 
intact staple line across the bowel, and when I eventually later re- 
insufflated, I could see the staple line even with the level of the 
visible levator muscles which is the exact spot I intended to divide 
the rectum.  For the meantime though, we had the specimen now up in 
our hands and we identified the inferior mesenteric artery again and 
then divided the mesentery proximal to it between Mayo clamps, 
ligating with 2-0 silk suture and then divided the distal descending 
colon with an automatic pursestring device, placed a #28 EEA 3.5 mm 
anvil, cleaned off the bowel as per my habit and placed a second 3-0 
Prolene pursestring as per my habit, and we determined at this point 
we had a good-looking donut size to expect from the proximal side and 
a good-looking area of bowel to have the stapler fire on, and with 
that, we were satisfied and dropped the anvil back in the abdomen.  I 
then took the specimen to the back table.  I opened it on the back 
table.  There was a residual ulcer that was posterior at the site of 
the previous cancer.  I measured the distal margin, it was 2 cm, and 
the proximal margin was close to 10 cm.  The rectosigmoid colon was 
then sent to Pathology as eventually were the two donuts from the 
stapler, the distal one marked as the final distal margin.  I re- 
insufflated the abdomen.  We irrigated the pelvis.  Hemostasis looked 
excellent.  We then performed a #28 EEA anastomosis, taking care to 
avoid any twisting in the colon mesentery.  Both donuts were 
excellent.  We insufflated the anastomosis under saline, holding the 
proximal and clamped off manually, and there was no evidence of leak. 
The anastomosis on rigid sigmoidoscopy was about 5 to 6 cm from the 
anal verge.  I then placed a 10 flat Jackson-Pratt in the pelvis and 
brought it out through the left mid quadrant 5 port site and sewed it 
in place with a 2-0 silk suture.  I then used the hand port to grasp 
the terminal ileum and came back along it for about a foot to where a 
piece would reach the anterior abdominal wall adequately, and then we 
made a circular incision around the right mid quadrant 5 port, 
dissected out wedge of skin and fat, made a cruciate incision in the 
rectus fascia, opened the muscle intact from its fibers and then 
enlarged the hole to two fingerbreadths, and passed out the small 
bowel, taking care to avoid any twisting in the mesentery.  We again 
checked this laparoscopically to make sure there was no twisting and 
that the inferior end on the skin was actually inferior, and it was. 
We placed a 16-French red rubber catheter as a stoma rod and sewed 
that in place with 3-0 Vicryl suture.  I then thoroughly irrigated the 

We placed a stoma bag and 
Mastisol


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## cynthiabrown (Aug 24, 2015)

I agree with you................


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