# Bowel resection w/ appendectomy



## nlbarnes (Oct 12, 2017)

We've got a difference of opinion regarding the appy.  Path states fibrous obliteration on the appendix.

44202 & 44970          OR            44202

Operative Findings: Large Meckel's diverticulum with adhesion right at this area to the omentum causing an obstruction and internal hernia with complete small bowel obstruction.  There was about 40-50 cm of small bowel with significant ischemic changes.  We decided to remove the appendix as well as resection of small bowel containing the ischemia and Meckel's

Details of Operation: We immediately looked in the abdominal cavity and salivary of dilated small bowel loops extending to the right lower quadrant was an ischemic segment of small bowel in the right lower quadrant.  We placed 1 more 5 mm trochar and wound 12 mm trocar in the left side of the abdomen.  We used these trochars to examine the small bowel.  We ran the small bowel from proximal to distal.  We able to identify a segment of small bowel with a Meckel's diverticulum with an omental band extending to the mesentery of the Meckel's causing a complete small bowel obstruction.  We cut this adhesive band which released the small bowel.  However there still seem to be an internal hernia with a small bowel twisted.  We therefore identified the cecum and ran the small bowel proximally from the  ileocecal valve backwards toward the ileum and jejunum.  By doing this I was able to reduce all the small bowel completely and identified the Meckel's diverticulum again and all the small bowel was completely released.
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At this time we planned for a resection.  We decided however first to remove the appendix.  We made a window at the base of the appendix at the cecum level.  We fired echelon at the current 60 blue load stapler across the base the appendix and a white load stapler across the mesoappendix.  The staple lines were clipped for hemostasis and the appendix was placed into an Endobag and removed through the 12 mm trocar site on the left side.  The appendix was noninflamed.
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We then grasped the Meckel's diverticulum.  We made a larger incision in the infraumbilical midline measuring about 4-5 cm.  We dissected down through the anterior midline fascia into the dental cavity.  We placed a wound protector in this wound.  We exteriorized the medical diverticulum as well as the small bowel through this wound.  This was done very easily.  We used a Doppler to identify Doppler flow.  The patient did have good blood flow to the entire area of small bowel around the diverticulum.  We therefore divided the small bowel with a 60 blue stapler about 5 cm proximal and distal to the medical diverticulum.  We made sure that it had good blood flow.  We divided the mesentery between clamps and ties.  We sent the specimen including the Meckel's off the table as a fresh specimen.  We then performed a side-to-side functional end-to-end anastomosis of the small bowel to itself but make it to matching enterotomies and using a 60 blue stapler for the anastomosis.  Once we did this however we are not happy with the way the small bowel looked because it was quite hemorrhagic despite the fact that it had very good blood flow.  We therefore decided to resect about a 40 cm segment of small bowel around this area to healthy small bowel.  We used a 60 blue stapler for both 


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## csperoni (Oct 12, 2017)

*I would bill for the appy*

The doctor SHOULD have in the op report stated WHY he/she decided to remove the appy.  But since you now have pathology to justify, I would bill for it.  My brief google search revealed that fibrous obliteration of the appendix can mimic acute appendicitis.  So, even a simple "based on the unusual appearance" we decided to remove the appendix would suffice.  My doc is currently pretty good with that stuff from the beginning.  You can always ask your doc to amend the report since it would seem that was clearly the reason, but it is not stated.  In my opinion, your pathology now justifies the billing.


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