# Hartmann procedure, small bowel resection, decompression of bowel



## ksb0211 (Dec 28, 2011)

Any thoughts on this one? I would appreciate any input.  I don't want to miss anything.
Thanks.

OPERATION PERFORMED
Exploratory laparotomy with Hartmann procedure, small bowel resection and decompression of bowel.

DESCRIPTION OF PROCEDURE
The patient was brought to the operating room after attainment of sufficient general anesthesia he was pretreated with antibiotics and prepped and draped in the usual sterile fashion.  Made a midline incision, opened the abdomen and extended the incision inferiorly down toward the pubis.  We found loops of bowel that were involved with the small bowel abscess and one wall of that abscess was actually the left colon.  We brought the small bowel up in sort of a cup-like almost an amphitheater-like area of abscess with green almost looked like succuss entericus.  We thought maybe that this was a primary small bowel problem and what we did, the small bowel was distended.  We put a clamp distally and then worked back some of the succuss entericus across this area of the small bowel and the small bowel although really involved with this abscess and constricted and it really looked bad there was no apparent perforation.  At this point, we looked down over in the left colon and the other wall of this abscess cavity was the large bowel which was extensively involved with diverticular disease.  Statistics being what they are, the feeling was at this point that there was no obvious problem with this small bowel other than the fact that it was badly involved with this abscess. Likely source of this abscess itself was probably the large bowel.  We went ahead and we resected the small bowel, took that out because it was just so indurated and inflamed.  We went ahead and took that down, handed off that specimen, left the small bowel into 2 pieces at this point and then transected the proximal sigmoid and then took down the mesocolon  using 2-0 silk ties and then the Harmonic scalpel, but we did not use the Harmonic scalpel as much we used ties.  We then came down distally and used the TA across the nondiseased portion of the sigmoid.  Once that was done we marked the ends of the remains of the sigmoid with two 2-0 Prolenes to mark them for subsequent reversal and then turned our attention to making our small bowel anastomosis.  We opposed the small bowel adjacent to itself and fixed the antimesenteric borders, introduced the GIA stapler and fired it and kind of oddly when we fired the GIA-75 about the last centimeter and a half the blade cut it, but it did not make an anastomosis.  We had both sides of the bowel with staples whether it was a bad load or something that we did technically that was not apparent to me.  We had a hole at the bottom of that anastomosis, so we just resected that additional 5 cm of small bowel on each side and just redid the anastomosis.  Fired the GIA once again and then this time we made a new anastomosis, switched out the GIA with new one and it fired perfectly and we had no troubles.  We then closed the remaining rent with a TA-60 with green staples and then closed the mesenteric defect.  We had taken this down with 2-0 silks as well.  We irrigated the abdominal cavity once we had mobilized this abscess and then we decompressed the small bowel back up into the stomach by squeezing the succuss entericus back in the stomach because we just needed more room in order to work.  We did that actually earlier on in the procedure.  We then irrigated the abdominal cavity, aspirated, placed a 10 mm Jackson-Pratt into the abdomen and covered the small bowel with the omentum and replaced back in its normal anatomic fashion.  Made a rent in the anterior abdominal wall and brought the colostomy through, but matured to the fascia using interrupted sutures of 2-0 silk and then we irrigated once again, aspirated and then closed this.  We irrigated probably with about 2 L of antibiotic containing saline.  We then closed with double stranded #1 PDS, irrigated the wound once again and closed with 3-0 Vicryl, then skin staples.  Then placed a sterile dressing and then matured the colostomy on the table.  The patient tolerated the procedure quite well.  Sterile dressings were applied.


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## tcooper@tupelosurgery.com (Dec 28, 2011)

I would use 44143 and 44120-51. I looked in the Medicare Edits and I do not show these two codes as bundled. I hope this helps.


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