# Exploratory Laparotomy. Ileostomy take-down with Ileorectal asnastomosis



## hcg (Aug 31, 2012)

First time in General Surgery practice & I need help on this one:

PREOPERATIVE DIAGNOSIS: History of clostridium difficile colitis, stsatus post total abdominal colectomy with diverting ileostomy.

POSTOPERATIVE DIAGNOSIS: History of clostridium difficile colitis, stsatus post total abdominal colectomy with diverting ileostomy.

OPERATION: Exploratory laparotomy, Ileostomy take-down with ileorectal anastomosis. Intraoperative proctoscopy.

INDICATIONS FOR SURGERY:
Patient with a host of medical problems over the last year, developed Clostridium difficile colitis and subsequently toxic colitis as a result of that. In an effort to save life, patient was taken to the operating room for a total abdominal colectomy with ileostomy. the operation was sucessful, although pt did have a prolonged recovery and multiple other medical conditions following that. After stabilization of the above mentioned medical conditions, pt wanted the ileostomy taken down. Risks including bleeding, infection, injury to the intra-abdominal organs, anastomotic disruption potentially requiring further surgery and the expected changes in bowel habits and frequent bowel movements were discussed at length with the patient and the questions were answered. The potential risk of exacerbation of the pt.'s known underlying health conditions, were also reviewed at length.

DESCRIPTION OF PROCEDURE:
The patient was identified. She received intravenous antibiotics preoperatively. Patient was brought to the operating room and placed in the supine position. General endotracheal anesthesia was administered. Foley catheter was inserted. A rigid proctoscopy to distance of 18 cm revealed no significant pathology within the rectum. The rectum was irrigated with betadine solution.

The lower quadrant ileostomy was identified, over-sewn with a single pursestring of silk and then the abdomen was prepped with chlorehexidine solution. An Ioban drape was utilized.

The midline laparotomy incision was reopened. Subcutaneous dissection was performed. Rectus fascia was incised in the midline. Sharp dissection was used to enter the pertioneal cavity. Exploration revealed only a modicum of intra-abdominal adhesions. Exploration of the pelvis using the Bookwalter retractor for retraction demonstrated the rectal stump, which is intact. I elevated the stump and dissected free some surrounding scar tissue to expose the stump and to confirm that it was a reasonable recipient for an anastomosis.

I then turned my attention to the right lower quadrant ileostomy, starting my work in the abdominal cavity. I dissected free the ileostomy from the anterior abdominal wall. Ultimately, I went to the skin. I excised the ileostomy and the surrounding thin vital skin. I continued my dissection down into the abdominal cavity, completely mobilizing the ileostomy. I chose to resect a few centimeters of ileostomy that traversed the abdominal wall and this was sent for pathological confirmation and labeled ileostomy.

I opened the terminal ileum and inserted a 28 mm EEA anvil, ssecuring it into place ewith a pursestirng clamp.

Having confirmed that the orientation of the small bowel was proper and that there were no twists, kinking or knotting, I then went to the pelvis, gently dilating the anus with EEA sizers. I pased a 28 mm EEA stapler up through the anus, into the rectum and into the previous rectal staple line. The spike was extruded int eh midportion of the staple line. Spike and anvil were married and an ileorectal anastomosis was created. Inspection confirmed excellent doughnuts. The terminal ileum was occluded just proximal to the anastomosis. The rigid proctoscope was again inserted and was used to examine the anastomosis noted at about 18 cm. The anastomosis was intact and patient. There were no evidence of bleeding and there was no leaking from the anastomosis.

The abdomen was then copiously irrigated with saline until the effluent was clear. The ileostomy site was closed with 2 layers of interrupted 0 Vicryl suture. The posterior layer was closed vertically to reapproximate the posterior rectus sheath anteriorly. The anterior rectus sheath was also closed vertically with interrupted 0 vicryl in a figure-of-eight fashion.

Sponge, needle and instrument counts were reported as correct. The rectus fascia was reapproximated in the midline with a continuous 0 loop PDS. The wound was irrigated with saline and the skin was close with staples. The ileostomy site was packed open and 3-0 nylons were leflt in the skin for purposes of delayed primary closure. Dry dressings were applied. The patient tolerated the procedure well without complication.

This is what I have:

V44.2
008.45

44626
44139

I probably missed something, so I need help. I appreciate all the help I can get.

Thank you.


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## hcg (Sep 5, 2012)

This is what I added:

V44.2
008.45

44626
44140
44139

I hope someone can help me with this.


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## Williealawishes (Jun 17, 2013)

I would only code the 44626.  I would not code the 44140 as it should be included in 44626, I would also not code 44139 because this patient already had a total colectomy.  The splenic flexure is already gone...only the end of the small bowel/beginning of large bowel remains and he also never noted any take-down in this area.  Hope my two cents helps!!


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## hcg (Jun 17, 2013)

Williealawishes said:


> I would only code the 44626.  I would not code the 44140 as it should be included in 44626, I would also not code 44139 because this patient already had a total colectomy.  The splenic flexure is already gone...only the end of the small bowel/beginning of large bowel remains and he also never noted any take-down in this area.  Hope my two cents helps!!




Thank you for your reply. I learned a lot since I posted this thread. And yes your two cents helped


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