# Lap proctectomy with partial colectomy. Help with code!



## l1ttle_0ne (Mar 1, 2016)

I'm wondering if anyone can provide me with their opinion on this surgery. Our physician did a Laparoscopic proctectomy with part colectomy and a diverting ileostomy. I can't find a code for this... I can find one for a total colectomy, but not a proctectomy with partial colectomy. Anyone have any insight?? We were contemplating billing a 44212 with a 52 modifier. Not sure if this is right?? Anyone have any idea's?? I would really appreciate it!!


PREOP DX: Rectal cancer
POSTOP DX: same

SURGEON: 

OPERATIVE PROCEDURE: 
1.  	Laparoscopic proctectomy with coloanal anastomosis and diverting ileostomy
2.  	Laparoscopic splenic flexure mobilization


FINDINGS: The rectum and sigmoid colon were resected based on blood supply from the inferior mesenteric artery. A stapled 32 mm end to end anastomosis was created- no air leak noted with excellent tissue apposition, no tension, and good blood supply. The tumor was examined on the back table and noted to be 2 cm from the distal margin. Donut was sent as well. Small amount of bleeding at the spleen controlled with floseal and surgicel

SCOAP GUIDELINES for RECTAL CANCER
1) Procedure done for palliation- No 
2) Was preop (neoadjuvant) treatement used? Yes
A. If yes, was radiation therapy used? Yes
B. If yes, was chemotherapy used? Yes
3) Was preop fecal continence adequate? Yes
4) Number of weeks between end of preop radiation therapy and surgery? 9
5) Was EUS TRUS or MRI used to define stage? MRI
6) What was the TNM stage (if known)? T3N0
7) Was distance of tumor from the anal verge defined? Yes 
A. If yes, was the distance determined by rigid scope, flexible scope and/or digital exam? Rigid and digital exam
B. If yes, was the distance determined after neoadjuvant therapy? yes
C. If yes, distance of tumor from the anal verge: (8 cm)
8) Was tumor fixed to underlying structrues: No 
A. If yes, was the distance dtermined after neoadjuvant therapy? 
9) Was a total mesorectal excision performed? Yes 
10) Was TME capsule intact? Yes
11) Was a protective stoma used? Yes
12) Was the anastomosis tested for leak with air or dye intallation? Yes- air test


DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where he was given general anesthetic. He was sterilely prepped and draped in the low lithotomy position. A pfannensteil incision was made, and the abdomen entered under direct visualization. This was followed with a 12 mm umbilical and a 5 mm LLQ port. The IMV was the clipped and transected at the tail of the pancrease. The sigmoid colon and transverse colon were mobilized from the retroperitoneum. The splenocolic and gastrocolic ligaments were divided. The inferior mesenteric artery was then clipped and divided.

The remaining sigmoid colon attachments wer scored from the retroperitoneum using electrocautery. Subsequently, the dissection carried down to the presacral space, which was dissected down to the levator muscles. The pelvic sidewalls were both scored conserving the mesorectal plane. Care was taken to preserve the hypogastric nerves. The dissection then proceeded anteriorly where the rectum was freed from the seminal vessels and prostate. There was very adhered planes, and the left pelvic sidewall had a bleeder controlled with a 3-0 vicryl sutures.. Having freed the rectum in its entirety using TME technique, the mesorectum was then divided and the rectum was transected at the levators using a contour stapler.

The colon was transected at the sigmoid descending colon junction and a 32 mm anvil head was sewn in place with a 2-0 prolene pursestring suture. A 32 mm end-to-end anastomosis was created. This was visualised with a rigid sigmoidoscope and tested with air and no leak was noted. Hemostasis was checked throughout the abdomen and noted to be excellent. Antibiotic irrigation placed in pelvis for three minutes. The splenic tear was noted and floseal was placed followed with surgicel. 

The ileostomy was prepared by making a circular incision in the RLQ. The rectus muscle was split and the terminal ileum brought through the incision. The Pfannenstiel incision was closed with running PDS sutures. Skin was closed with subcuticular sutures followed with glue on skin. Sepra film was placed around the ileostomy. The ileostomy was matured with 2-0 and 3-0 chromic sutures. No complications. 



Complications: none
EBL 200 mL. 
Specimens: Rectum and sigmoid
Distal rectal donut


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## l1ttle_0ne (Mar 3, 2016)

Anyone?? I could really use some help!


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