# Exploratory/Repair Enterotomies



## Trendale (Aug 10, 2009)

please let me know if this is the code to use and if a modifier 52 should be attached. I m a little confused on what PX was terminated. The two enterotomies were repaired. The Exp Lap is included. Thanks for any help!

44615

PREOPERATIVE DIAGNOSIS:  Small-bowel obstruction secondary to
metastatic breast cancer.
POSTOPERATIVE DIAGNOSIS:  Small-bowel obstruction secondary to
metastatic breast cancer.
NAME OF OPERATIONS:
1 Exploratory laparotomy.
2 Repair of enterotomies times 2.
ANESTHESIA:  General anesthesia with intubation,
ASSISTANT:  <__________>
ESTIMATED BLOOD LOSS:  About 30 cc.
GROSS OPERATIVE FINDINGS:  Once we had entered the abdomen through a
standard mid abdominal incision,  we noticed that the abdominal wall
was very thickened and likely representing carcinoma.  The large and
small intestine were completely encased in cancer, making it very
difficult to really tell what was intestine and what was cancer.  We
actually had 2 enterotomies that we had to repair using 3-0 Vicryl.
DESCRIPTION OF OPERATION:  The patient was brought to the operating
room, positioned on operating table in supine fashion.  After
induction of anesthesia with intubation, the abdomen was prepped and
draped in the usual sterile fashion.  A mid abdominal incision was
made and slowly we progressed through this very thickened abdominal
wall.  We now began using sharp dissection with Metzenbaums until we
were now able to slowly go past the abdominal wall into what appeared
to just small and large intestine encased in cancer.   An enterotomy
was made on the colon, which was repaired with 3-0 Vicryl in one layer
since the bowel was very thin and did not really want take the
sutures.  Then there was an enterotomy in the small intestine.  In a
similar fashion, we approximated with 3-0 Vicryl as well.  At this
time, we made a decision that it would not be the best interest of the
patient to continue with the surgery.  Again, the intestines, both
large and small, were completely encased with cancer, making this
surgery nearly impossible to complete and if we continued, we would
continue to just enter the small intestine and large intestine,
causing and multiple enterotomies, which may eventually need to
peritonitis and death.  We therefore decided to terminate the
procedure at this point in time, being that there was nothing that
could be done surgically due to the advanced nature of disease.
We approximated the fascia with interrupted #1 PDS.  Then when we came
to the areas where the enterotomies were found, we just left this area
open to be packed and hopefully it will heal by secondary intention.
The skin was then loosely approximated with staples up to the point of
the enterotomies, which was left open to be packed with wet-to-dry
with saline.  A clean dressing was applied and patient was taken back
to recovery.


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## jaimewicklund (Aug 10, 2009)

I would code this out as an exploratory lapartomy. I would not code the suture repairs of the intestine (entertomies) as it appears that they were made by the doc while exploring.....just my opinion.


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## mjewett (Aug 13, 2009)

I think the doctor was implying that due to the extent of the cancer they would not be able to perform a bowel resection and that the idea of bowel resection was terminated. The surgery actually performed was exploratory lap, you should not bill for the enterotomy repairs.


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