# Need help with abd perineal resection



## Jarts (Oct 22, 2009)

We are unsure which code is correct for the following procedure ~ 44155 or 45110?

POSTOPERATIVE DX: Rectal Cancer.

PROCEDURE PERFORMED: Abdominoperineal resection

FINDINGS AT SURGERY: Initial evaluation of the pelvis revealed a significant lesion with extensive fibrosis from the previous radiation. Ultimately we were able to get below the lesion and fire our stapler, but the margin was approximately a centimeter, and I felt that it was not an adequate resection and thus proceeded with an abdominoperineal resection.

PROCEDURE IN DETAIL: Low midline incision was made, carried into the abdominal cavity, and extended up around the umbilicus. A Bookwalter retractor was put into place. The small bowel and contents was packed into the upper abdomen. The abdomen, due to her obesity was a very limited working space. She also had a very narrow pelvis.

We began the dissection by incising the lateral peritoneal attachments of the sigmoid colon down to the lvel of the sacral promontory. The mesentery was then divided up to an area where I thought would be adequate for a handle and was in the mid sigmoid. This was divided with the GIA stapler. Then the mesentery was divided with double clamp and tie techniques. The ureters were identified and kept out of harm's way.

The retrorectal space and a vascular plane was then entered and, using electrocautery, was dissected. The same technique was used on the lateral stalks. She had a very deep narrow pelvis, which made the anterior dissection very difficult. Extensive finger dissection and dissection of the retrorectal space was done using both back and forth techniques as well as the St. Mark's retractor. Ultimately we were able to get down to and into the level of the levators and isolate the rectal tube.

The Contour stapler was then used and fired across the distal rectum. The specimen was then opened, and there appeared to be a less than 2 cm margin with an obvious tumor. Thus, due to the close margin and the difficulty of the dissection, I felt it would be in her best interest to proceed with a completion abdominoperineal resection.

The perineal skin and anus was then grasped with a Kocher clamp and then the incision was made in intersphinteric groove circumferentially and then dissected into the ischiorectal fat laterally circumferentially and posterior to the midline raphe. The proximal staple line was ultimately identified and retracted into the perineal opening, and the remainder of the rectum and anus was removed with circumferential dissection. The area was then inspected for hemostasis.

The levators were then reapproximated with interrupted 0 Vicryl sutures in multiple layers, thus closing the perineal floor. The skin was then closed with interrupted 0 Vicryl sutures. The surgeons both reprepped and draped. The abdomen was then irrigated with copious amounts of normal saline and inspected for hemostasis. The pelvis was then inspected, which appeared to be very dry, and then decision was made to repair the proximal colostomy.

She had extensive amount of fat and epiploica on the bowel which made the mesentery very thick. Thus the decision was made to clean off approximately 2 inches of epiploica to allow adequate length to bring up for the colostomy. A standard trephine incision was made in a previously marked site, and the bowel was brought through the abdominal wall. Initially I had some concern about the possibility of some congestion and poor blood supply but this was relatively short-lived and it was just some venous congestions. In fact, when we cut open the end of the colostomy to mature it, there was good bleeding and mucose was very pink and healthy.

The colostomy was then matured with interrupted 3-0 Vicryls in a standard rosebud fashion. The pelvis was then irrigated with normal saline. A 15-French round Blake drain was placed in the pelvis. We checked to see of the peritoneum over pelvis would close, there was no excess peritoneum to close. The Penrose drain was sutured into place with interrupted 3-0 Vicryl The decision was made to close.

Julie


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## ASC CODER (Oct 22, 2009)

45110 

That would be my opinion however not my specialty.


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## Jarts (Oct 22, 2009)

Thanks for your input!!


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