# Bowel Resection



## jan g (Jul 14, 2014)

Appreciate any help with this surgery....so far I have CPT 44140 for the sigmoid resection with anastomosis; CPT 44955 for the appendix as it was positive for periappendicitis.  Then I get confused after that.  Should I use CPT 44151 for the diverting ileostomy and CPT 44146 for the Brooke ileostomy and CPT 44660 for the colovesical fistula.  Then what about modifier 59?  Also using CPT 47600 for the cholecystectomy as it was positive for invasive carcinoma.


OPERATIVE INDICATIONS: 
A 75-year-old female who presented initially with a moderate trauma in which she fractured her right hip. She was noted on her evaluation to have severe diverticulitis with a wide-open colovesical fistula. She underwent repair of her hip fracture and now presents to the operating room following IV fluids, antibiotics, and a PARQ conference in which all questions were answered for definitive management of her diverticulitis. 
OPERATIVE FINDINGS: 
1. Large inflammatory mass in the pelvis involving the sigmoid colon, bladder, distal small bowel, appendix. 
2. Tumor mass in the mid ileum, which is frozen section positive for a poorly differentiated carcinoma. 
3. Large stone cholelithiasis with probable impending cholecystoduodenal fistula. 
4. Multiple positive lymph nodes around the pancreas and porta, one of which is frozen section positive for a metastatic adenocarcinoma. 
OPERATIVE DESCRIPTION: 
Under general endotracheal anesthesia, the abdomen was accessed through a midline incision.Dissection was carried through the abdominal wall predominantly with electrocautery. 
Upon entering the abdomen, initially the inflammatory mass and the sigmoid diverticulitis was the main focus of attention. The sigmoid colon was bluntly dissected free from the dome of the bladder. This released a large quantity of entrapped stool and purulent material. This was all aspirated and the pelvis was copiously irrigated. The mid sigmoid colon was then transected with a GIA stapler. The mesentery was taken with a LigaSure type device in close proximity to the bowel wall. This was done down into the true pelvis to where the normal rectum was encountered. Part of the rectal pedicles were taken with the LigaSure as well and the mid rectum was then transected with another GIA stapler and the sigmoid colon was removed from the abdomen. Intestinal continuity was then reestablished with an end-to-end EEA anastomosis using a 33 mm circular stapler. The intraoperative leak test was then performed by insufflation of the rectum and distal sigmoid colon with air under water and no leak was identified. Following this, attention was directed to the cecum which was brought up into the mid abdomen. The appendix appeared to be involved in a dense inflammatory process. It is unclear whether this was diverticulitis or whether this was 
independent appendicitis. The appendix was removed and the inflamed stump of the appendix was closed with interrupted silk sutures, imbricating it into the wall of the cecum. Once this was accomplished, the terminal ileum was inspected and approximately 25 cm proximal to the cecum, the ileum was divided and a diverting end ileostomy was created. The distal ileum was sewn to the proximal ileum approximately 10 cm from the end of the bowel. This was tacked together with a series of interrupted silk sutures to facilitate an ileostomy takedown sometime in the future. A defect was created in the anterior abdominal wall and the end of the bowel was brought up to the skin and later matured into a standard Brooke ileostomy using interrupted Vicryl suture. The abdomen was copiously irrigated. Two drains were placed in the deep pelvis, one associated with the anastomosis and one associated with the bladder. The bladder was filled with normal saline and methylene blue. The colovesical fistula, which had been bluntly interrupted, was clearly identified and it was sewn closed with interrupted Vicryl sutures and protected with a JP 
drain. Prior to the creation of the ileostomy, a firm lump was noted in the mid ileum. This appeared to be a neoplastic process and this small section of bowel was resected in its entirety and this was frozen section positive for a poorly differentiated carcinoma. Next, the gallbladder was palpated. 
Because of its firmness in the large cholelithiasis and now the cancer diagnosis, we decided that it would be unwise to leave her gallbladder, so the midline incision was extended to allow at least modest exposure to the gallbladder. The liver was packed down. The gallbladder was released from local adhesions to the omentum and part of the duodenum. The fundus of the gallbladder was dissected free from the liver. It was entered and a large quantity of very purulent material was 
removed from the gallbladder. This was also sent for culture. The gallstones were removed and the dissection was carried down to the infundibulum of the gallbladder, where there appeared to be a large opening that might be associated with the duodenum. We elected not to investigate this any further. A pursestring suture was then placed in the infundibulum of the gallbladder and a 16-French Foley was placed through the right upper quadrant of the abdominal wall and placed within 
the infundibulum remnant of the gallbladder as the pursestring suture was secured. The abdomen was then copiously irrigated and inspected one last time and then closed with a 10 JP drain 
in proximity to the cholecystostomy tube and 2 drains in the deep pelvis. The abdominal wall was closed firmly and the subcutaneous tissue and skin were dressed with a wound V.A.C. device. The patient tolerated all this actually quite well, was transferred to the recovery room and then back to the floor in stable condition.


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## cynthiabrown (Jul 18, 2014)

Jang...whenever a fistula is closed by means of resection of colon, the fistula closure is included . Look at 44145 for sigmoid colon, 44955 for appy, 47600-59 for gall bladder and 44310 for diverting ileostomy.


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