# Lap sigmoidectomy, repir of bladder fistula



## MEZIESKY (Aug 12, 2011)

Help please. This is a lap sigmodectomy and repair of colovesical fistula.  I'm looking at 44204,44213 but having trouble with the fistula  repair. The code 45800 for closure of rectovesical fistula is open. Any idea's. Op note to follow.

Patient remained in modified lithotomy position. Her abdomen and perineum
were then prepped and draped in sterile fashion. After local infiltration, a
supraumbilical incision was made. Pneumoperitoneum achieved with a Veress. A
12-mm bladeless trocar was inserted. Then under direct vision, a right
lateral 5 was placed. A site was selected in the left lower abdomen. A 7 cm
incision was then made, carried down through all layers in a muscle-sparing
manner. Peritoneum was elevated in size. This was extended with cautery.
The inner flange of the GelPort was then placed and the GelPort was secured
in the usual manner. With lubricated, nondominant hand within the wound, the
abdomen was explored. There were some adhesions of the small bowel to the
anterior abdominal wall on the right lower quadrant. These were lysed
without difficulty. The upper abdomen appeared within normal limits, but as
visualization down the pelvis was performed, there was obvious adherence of
the sigmoid to the bladder dome. This was taken down with harmonic scalpel
and blunt dissection until clear. There was a fistulous tract that was
easily identifiable. The white line of Toldt was scored in the paracolic
gutter on the left mobilizing the sigmoid medially. Both ureteral stents
were palpable and free from any harm. The IMA pedicle was encircled and
divided via low ligation technique using Echelon 45 stapler with a vascular
load. The rectosigmoid was soft and pliable below the fistula site. It was
divided with an Echelon 45 with a blue load. Two firings were required. The
position then changed by standing between the patient's legs and mobilizing
the splenic flexure. Once this was clear, the bowel was exteriorized. A
site for proximal transection was selected. A pursestring clamp was applied.
The pursestring was created with 2-0 Prolene and then the bowel was
transected. An EEA 29 stapler was selected. The anvil was placed through
the open end of bowel and the pursestring suture tied. This was returned to
the abdominal cavity. This easily reached down into the pelvis. A flap of
omentum was now mobilized off the transverse colon, which also reached to the
dome of the bladder without difficulty. At this point, the assistant went
between patient's legs irrigated the rectum out with bactericidal agent.
After serial dilatation, the EEA stapler was advanced to the rectosigmoid
staple line. The pin was deployed just anterior to the staple line. The
anvil and pin were then coupled. The device closed and then fired. There
were 2 complete donut rings of tissue when examined on the back table. The
bowel was clamped proximal to the anastomosis and gently insufflated. There
was distension of the bowel without any evidence of air leak. At this point,
the fistula of the bladder was closed with figure-of-eight 2-0 Vicryl. The
omental pedicle was now brought down to the field. It was also secured to
the repair site with 2-0 Vicryl held at either end with a Lapra-Ty. The
abdomen was copiously irrigated and aspirated until clear. JP drain was
introduced through the 12-mm umbilical site, brought out through the 5
lateral abdominal site, secured to the skin with 2-0 nylon. The drain rested
down in the pelvis. All ports were now removed and the abdomen desufflated.
Fascia of the umbilicus closed with interrupted #0 Vicryl. The GelPort site
was closed with a running 0 Vicryl with the peritoneum and posterior sheath
and a running 0 loop PDS to the anterior fascia. All skin was closed with
staples. Dry dressings were then applied. Patient tolerated procedure very
well. She was taken to the recovery room, extubated in satisfactory
condition.

Thank you,
Marie


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