# removal mesh and small bowel resection x 2 w/primary anastomoses



## AR2728 (Jun 25, 2014)

I really need some help on this asap-any assistance is greatly appreciated.  I'm looking at 44120 44121 and 49402 for the mesh removal as this was attached to jejunum and not simply abdominal wall.  

Here is a the bones of the operative report:

There were significant adhesions of omentum. The incision was opened up down to where mesh was palpable. At this point there were dense adhesions of omentum and small bowel. Adhesions of omentum were carefully taken down. The small bowel was evaluated proximally and the proximal jejunum was decompressed. The distal jejunum was down into the pelvis where there were dilated small bowel loops. On initial entrance into the abdomen this was blocked from view due to adhesions. The patient had adhesions of multiple small bowel loops just at and inferior to the umbilicus where the patient's mesh was exposed to the abdominal contents. The remainder of the mesh appeared to be properitoneal. Almost the entire ileum was entirely decompressed. There was a tight obstruction where four to five loops of ileum were tightly adhesed and kinked off at the area of exposed mesh. Approximately 40 cm proximal to this was another loop of small bowel from the jejunum which was also adhesed up to the area of exposed mesh. Extensive adhesiolysis was performed very slowly. There were some serosal tears. The more proximal portion of jejunum where it was stuck to the exposed mesh was able to be freed up by removing a small piece of mesh adherent to this piece of jejunum. There were serosal tears that were repaired. The bowel was then run down to where there were tight adhesions of four to five loops at about the distal jejunum and proximal ileum. The more proximal jejunal loop had been freed up and was also adhesed in this area. Careful adhesions were taken down which were very dense. Loops were able to be identified but did extend up where they were tightly adhesed and where there was a tight turn and a kink and a complete obstruction with the distal bowel completely decompressed. Bowel loops were carefully taken down along with some adherent mesh with careful sharp dissection. During taking down of adhesions inferiorly the bowel was entered and was quickly closed. This loop was able to be freed up and closed with a running silk suture without any significant spillage. The patient had three to four more loops that were still densely adherent and therefore it was elected to resect the portion of exposed mesh. An approximately 8 cm long area of exposed mesh was removed with sharp dissection of the mesh right at the edge of the adhesions of small bowel. All small bowel adhesions to the anterior abdominal wall were in this small area of exposed mesh just at and inferior to the umbilicus. The mesh in this area was sharply divided right at the edges of where the small bowel was adherent and the entire area of tightly adherent small bowel loops were allowed to fall away from the abdominal wall. Evaluation revealed the enterotomy which had been closed quickly with silk. There were also very tight dense adhesions. The involved bowel in this segment was approximately 15 cm long. About 40 cm proximal to this was the small single loop of more proximal jejunum. Small bowel was dilated up into this group of adhesions to the exposed mesh. Small bowel was completely decompressed distally. As the adhesions were localized and because of the density and the tightly scarred down mesh, it was elected to resect the involved areas. The proximal jejunal loop was resected with approximately 5 cm resected and a stapled side-to-side functional end-to-end anastomosis was performed. The bowel was healthy at this point and was not significantly dilated. It did dilate distal to this and then extended up into the area of adhesions at the junction of the distal jejunum and the ileum. This entire area was resected with all bowel that was tightly adherent to resected mesh removed. The more distal resected bowel segment was a 15 cm segment. This was resected and a hand sewn two layer anastomosis was performed. Remainder of the bowel was healthy and there was no other further exposed mesh. It appeared that the mesh was exposed to the smallbowel just in this small 8 cm area. The small bowel was run from ligament of Treitz all the way down to the ileocecal valve and there was no further obstruction. Small bowel was decompressed. The ileum was normal. The uterus was shrunken with a benign fibroid noted. Both ovaries were shrunken and without masses. The liver did have small calcified granulomata. The stomach was grossly normal and an NG was in place at the end of the procedure. The wound was irrigated and then closed.


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## AR2728 (Jun 26, 2014)

Any suggestions?


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## cynthiabrown (Jul 18, 2014)

I agree


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