# Colon Surgery



## latonya78 (Nov 14, 2012)

Hello,  I need help with the following Procedure.  I am new to this type of surgery.



PREOPERATIVE DIAGNOSIS:  Ovarian carcinoma.
POSTOPERATIVE DIAGNOSES:
1.  Stage IIIC papillary serous ovarian carcinoma.
2.  Secondary tumor involving colon, omentum, peritoneum.
NAMES OF PROCEDURES:  Exploratory laparotomy suboptimal tumor debulking partial colon resection with ileocolonic anastomosis.
FINDINGS:
1.  Widely metastatic disease.
2.  Large tumors greater than 10 centimeters in diameter involving the transverse colon as well as the ascending colon.  Multiple implants involving the peritoneum, pelvis obliterated.
SURGEON:  John McBroom, M.D.
FIRST ASSISTANT:  Dana Simpson, PA.
ESTIMATED BLOOD LOSS:  1000 milliliters.  Two units of packed red blood cells, 4 liters of crystalloid given.
URINE OUTPUT:  400 milliliters.
COMPLICATIONS:  None.
FINDINGS:  Frozen section analysis reflected papillary serous carcinoma consistent with ovarian or primary peritoneal primary.
DESCRIPTION OF PROCEDURE:  After consent was obtained, the patient was taken to the operating room and underwent general anesthesia without incident.  She was placed in low lithotomy position, prepped and draped in the usual sterile fashion.  Foley catheter was inserted sterilely.  A vertical incision was made from the pubic symphysis to approximately 2 fingerbreadths below the xiphoid process.  This incision was carried down to the peritoneum.  The peritoneum was entered sharply.  Exploration of abdominal contents reflected diffuse disease that was deemed not able to ultimately debulk; however, there were 2 large masses involving the transverse colon and omentum as well as the ascending colon.  Attention was paid to the right abdominal sidewall.  The peritoneal incision was made level of the white line of Toldt.  The retroperitoneum was developed with some difficulty during this dissection and incidental colotomy was noted.
The incision was carried inferiorly to the level of the pelvic brim.  The right ureter, external iliac artery and common iliac were identified.  A vessel loop was placed around the ureter to keep it out of the surgical field.  This incision was extended superiorly then to the level of the hepatic flexure.  Decision was made to sacrifice the colon in this region and remove the tumor.  The peritoneal incision was then extended to approximately 12 centimeters away from the ileocecal junction.  A GIA was placed across the distal ileum and fired.  Next, the mesentery proximal to the hepatic flexure was separated with a Kelly clamp.  A GIA was placed across the descending colon and fired.  The retroperitoneum was further developed.  Windows were made in the mesentery which was infiltrated with tumor.  Kelly clamps were used to clamp the pedicles which were transected with the Metzenbaum scissors and secured with 0 silk.  Specimen was delivered distal ileum and ascending colon then passed off the field with a large greater than 10 centimeter mass.  Next, attention was paid to the upper abdomen.  There was noted to be the gastrocolic ligament as well as the greater omentum appeared to be completely replaced with tumor.  This appeared to be infiltrating into the transverse colon superficially.  The descending colon appeared to be relatively free of tumor in order to anastomose the small bowel to the descending colon and removed the bulk of the tumor, the decision to remove the remaining transverse colon was made.  The peritoneal incision over the white line of Toldt was made and the retroperitoneum was developed.  The descending colon was mobilized medially taking care not to damage the underlying kidney or ureter.  The splenic flexure was mobilized and transected using electrosurgical instrument.  Windows were made in the short gastric arteries.  The gastrocolic ligament was infiltrated with tumor. The  pedicles at the gastric arteries were clamped with Hem-o-Lok clips and transected.  Next, the GIA was placed across the distal transverse colon distal to the splenic flexure.  A GIA-75 was placed and fired.  With some difficulty, the pedicles were created in the mesentery.  This similarly was almost completely infiltrated with tumor.  Pedicles were created with the Kelly.  These pedicles were transected with Metzenbaum scissors and the pedicles were secured with 0 silk.  Next, the specimen was passed off omentum, _____ gastrocolic ligament and transverse colon as well as tumor mass.  Next, the distal ileum, the antimesenteric portion, was brought in proximity to the antimesenteric portion of the descending colon.  Silk sutures 3-0 with a seromuscular stitch were used to maintain this approximation.  The small colotomy was made in both the descending colon as well as the distal ileum.  A GIA-75 was then placed through these colotomies and fired, thus producing the anastomosis.  The remaining colotomy was grasped with Allis clamps and a GIA was then subsequently placed across this and fired.  The staple line was oversewn with 3-0 Vicryl with interrupted Lembert sutures.  The anastomosis was carefully inspected and appeared to be intact.  The distal portion of the anastomosis, the bowel distal to this was approximated with 3-0 silk in a seromuscular technique to ensure stability.  There was a tumor plaque that appeared to be covering the pelvis making accurate identification of the structures difficult as this was suboptimal debulking.  The procedure was terminated at this point having removed the 2 largest masses.  This left remaining multiple small implants as well as a tumor plaque in the pelvis.  The fascia was approximated with #1 PDS in a running nonlocking fashion.  The skin was approximated with staples.  The patient was awakened from anesthesia, taken to recovery in stable condition.


The following codes were submitted:  44160 and 44139.   I do not agree with 44139.


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## onetwothree (Nov 14, 2012)

You cannot use code 44160 because there is no ileocolostomy, I think 44140 with add on code 44139 is correct. There is mobilization of splenic flexure performed. You have to use add on code 44139.


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## latonya78 (Nov 14, 2012)

After speaking with a former co-worker regarding this case, she came up with the same answer. Thanks alot for your help.


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## vkratzer (Nov 19, 2012)

44160 is correct.  The physican removed a segment of the colon and terminal ileum and performed an anastomosis between the remaining ileum and colon.  44139 is only billable with codes 44140-44147.

V. Kratzer


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