# To use the 22999 or not to use it



## maine4me (Jun 11, 2012)

I need help with this rather complex operative note.  The doctor has coded it as follows:     49565 - LT
                49561 - RT
                49568
                11008
                44005 - 59
                44120
                44160
                22999 (compartment separation)

In reading this note I must be missing the portion that applies tot he 22999.  Can some one guide me in the correct direction?

PREOPERATIVE DIAGNOSIS:  
1. Peristomal hernia with small bowel obstruction.
2. Recurrent ventral incisional hernia.
3. Exposed abdominal wall mesh.
4. Severe COPD.

POSTOPERATIVE DIAGNOSIS:  
1. Peristomal hernia with small bowel obstruction; mid ileal stricture.
2. Recurrent ventral incisional hernia.
3. Exposed abdominal wall mesh.
4. Severe COPD.

OPERATION:  
1. Exploratory laparotomy and extensive lysis of adhesions (3-1/2 hours).
2. Excision of abdominal wall mesh.
3. Reversal of ileostomy with ileo-left transverse colonic anastomosis.
4. Limited segmental resection of the mid ileum with entero-enterostomy.
5. Repair of peristomal hernia with collagen matrix.
6. Repair of ventral incisional hernia with collagen matrix (onlay) and extensive
bilateral abdominal wall component separation.

ANESTHESIA:  General orotracheal by Grand View Anesthesia Associates.

INDICATIONS FOR PROCEDURE:  84-year-old Caucasian female with severe COPD.  In the 1990s,
the patient underwent sigmoid colon resection for carcinoma and repair of a subsequent
ventral incisional hernia with mesh (Dr. Eicher).  In approximately 2007, the patient
presented with a small bowel obstruction and I performed an exploratory laparotomy with
dissection of the involved small bowel from the abdominal wall mesh and lysis of
adhesions.  In November-December 2011, the patient presented with an incarcerated
recurrent ventral incisional hernia at the epigastrium, requiring surgery.  Dr. Flatau
performed this surgery and, after dissection of the hernia sac, the patient required a
right hemicolectomy for abdominal wall closure.  During that right hemicolectomy, a large
amount of fecal spillage occurred, resulting in the decision to close the left transverse
colon with a transverse application of a stapler and the creation of a Brooke ileostomy
in the right lower quadrant.  The patient required a limited epigastric abdominal wall
component separation at that time to effect closure of the abdominal wall musculature.
After an extremely stormy postoperative course, the patient developed a recurrent
epigastric ventral incisional hernia, exposed mesh in the midline scar, and a large
peristomal hernia.  The patient now presents with a near complete small bowel obstruction
apparently from the peristomal hernia at the right lower quadrant ileostomy.  

OPERATIVE FINDINGS:  The patient had extensive intra-abdominal adhesions, as well as
adhesions to the anterior abdominal wall.  Additionally, the patient had mesh in the mid
and lower abdomen.  An extremely large peristomal hernia was encountered, causing a
complete small bowel obstruction.  In addition, approximately 60 cm proximal to the
ileostomy stoma, the patient had a significant mid ileal stricture.  There was also a 8 x
10 cm recurrent ventral incisional hernia in the epigastrium.  Lastly, the rectus
abdominis muscles on each side were markedly retracted laterally.

PROCEDURE AND FINDINGS:  Patient was brought to the operating room and placed on the
operating table in the supine position.  After general orotracheal anesthesia had been
accomplished, a time out procedure was also accomplished, correctly identifying the
patient, proposed procedure, and laterality of proposed procedures.  A Foley catheter was
then inserted.  The abdominal wall was then prepped and draped around the ileostomy
stoma.  An incision was made at the mucocutaneous junction in a circumferential pattern,
and carried down into subcutaneous fat.  The mucocutaneous junction at the ileostomy was
then closed using a running locking suture of #0 silk.  At this point, the abdomen was
reprepped and draped.  The patient's previous vertical midline incision scar was then
excised in its entirety.  Incision was carried down into the subcutaneous fat (where
present), and entrance was made into the epigastric hernia sac.  The entire scar, having
been excised, the incision was carried down to the anterior abdominal wall muscular
fascia.  This was incised in the midline.  Once entrance into the epigastric hernia sac
had been accomplished, and entrance into the peritoneal cavity also accomplished, the
parietal adhesions of the small bowel to the anterior abdominal wall were divided under
direct vision and sharp dissection.  At this point, multiple adhesions were encountered
and these adhesions were sharply divided.  An extensive lysis of adhesions was required,
lasting approximately 3-1/2 hours.  Once this had been accomplished, the abdominal wall
mesh, which was intraperitoneal, was then excised from the anterior abdominal wall.  At
this point, dissection was initiated around the previously closed ileostomy.  This
dissection progressed into the subcutaneous fat, and finally down to the abdominal wall
musculature.  During the course of this dissection, an extremely large peristomal hernia
sac was encountered.  Once entrance had been made through the ileostomy muscular
aperture, the terminal ileum was brought into the peritoneal cavity.  At this point, the
remaining peristomal hernia sac was excised.  From this point, additional lysis of
adhesions ensued.  It was at this point that the mid ileal stricture was encountered.
After all of the small bowel adhesions had been divided, it was ascertained that the mid
ileal stricture required resection.  The peristomal muscular defect was then closed using
a running #1 Prolene suture.  The small bowel contents were then milked in a retrograde
fashion into the stomach and aspirated by the patient's NG tube.  The mesentery to the
distal segment of the colon at the left upper quadrant (left transverse colon), was then
divided.  A pursestring suture of 3-0 Prolene was then placed in the colonic wall.  The
head of a 29 mm circular stapler was then placed in the colonic lumen and the pursestring
suture tied around the shaft of the stapler head.  The ileostomy stoma and its adjacent
mesentery was then divided.  The mesentery vessels were ligated with 3-0 Vicryl ligatures
and the EnSeal sealing device.  The point of transection was in the small bowel, was then
divided transversely using a GIA stapler.  Going approximately 15 cm proximal, a small
antimesenteric enterotomy was placed in the terminal ileum and the 29 mm stapler device
was advanced through the enterotomy to the distal end of the small bowel that had been
closed with staples.  The trocar was brought out through the staple line.  Then, the
terminal ileum was positioned in the left upper quadrant and the stapler was approximated
and fired.  The stapler device was then removed from the enterotomy and the enterotomy
was closed in a transverse fashion using a single application of a TA 60 stapler.  The
anastomosis was checked and appeared intact.  Therefore, the mesentery between the
terminal ileum and the left transverse mesocolon was approximated using a running 2-0
Vicryl suture.  

Attention was then turned to the region of the mid ileal stricture.  Approximately 10 cm
of terminal ileum required resection.  Therefore, the mesentery to this portion of the
small bowel was divided using 3-0 Vicryl ligatures and the EnSeal device.  Once this had
been accomplished, distal margin of resection was transected and, using a pursestring
suture, the head of a 29 mm circular stapler was placed in the distal segment of the
small intestine.  The pursestring suture was tied around the shaft of the stapler head.
Attention was then turned to the proximal margin of resection.  This was transected using
a GIA stapler.  The segment that was resected was removed from the field.  Going
approximately 20 cm proximal to the proposed anastomosis, a small linear enterotomy was
made in the antimesenteric portion of the ileum.  The stapler was advanced distally to
the closed end of the small intestine.  The trocar was brought out through the staple
line.  The stapler head was applied to the trocar and the bowel correctly positioned and
the stapler was approximated.  The stapler was fired and then removed from the
anastomosis.  The anastomosis appeared intact.  The stapler, having been removed through
the enterotomy, the enterotomy was closed in a transverse fashion using a single
application of a TA 60 stapler.  The two edges of the mesentery were then approximated
using a running 2-0 Vicryl suture.  At this point, the bowel was returned to the
peritoneum.  The peritoneal cavity was irrigated with copious amounts of normal saline
which was aspirated.  There was no apparent active bleeding.  At this point, it became
evident that in order to effect a midline abdominal wall muscular closure, a bilateral
abdominal wall component separation was required.  Dissection was then carried laterally,
just above the muscle wall, laterally in both directions.  At this point, on each side,
just lateral to the spigelian line, a vertical incision was made through the fascia.
This went from the costal arch on each side, to the region of the symphysis pubis.  This
allowed approximation of the abdominal wall and the abdominal wall muscular closure was
accomplished using a single layer running suture of #1 Prolene with the knots buried.  At
this point, in order to reinforce the closure, two sheets of collagen matrix (Veritas)
were sutured together and approximated to the anterior abdominal wall.  One of these
sheets of Veritas was 12 x 25 cm, and the other was 6 x 18 cm.  Once this was
approximated against the anterior abdominal wall musculature on the superficial surface,
a flat Jackson-Pratt drain was placed on each side and brought out through the skin at
each costal margin.  Subcutaneous tissues were then closed using a running 2-0 Vicryl
suture.  Skin was closed using the staple gun.  The subcutaneous tissues at the previous
ileostomy were closed using a running 2-0 Vicryl suture.  The skin at the previous
colostomy was loosely approximated with staples and two wicks of 1 inch plain packing
gauze were placed at either end of the wound to promote drainage.  

The Jackson-Pratt drains were activated, and the patient having tolerated the procedure
surprisingly well, was taken to the surgical intensive care unit in stable condition.
Sponge and needle counts correct X 2.  Instrument count correct X 1.  Estimated blood
loss - 500 cc.  A abdominal binder was also placed.


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