# Exploratory laparotomy, takedown of colostomy with colorectal anastomosis



## hcg (May 3, 2013)

Can someone please help me with this procedure. The code that I used was 44625, but I am not sure about it. All information will be greatly appreciated. Thank you.

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PREOPERATIVE DIAGNOSIS: History of perforated diverticulitis status post colostomy.
POSTOPERATIVE DIAGNOSIS: History of perforated diverticulitis status post colostomy. Modest intraabdominal adhesions.
SURGEON: Dr. A
ASSISTANT: Dr. B
ANESTHESIOLOGIST:
ANESTHESIA: General.
OPERATION: Exploratory laparotomy, takedown of colostomy with colorectal anastomosis, takedown of the
splenic flexure, intraoperative proctoscopy.

ESTIMATED BLOOD LOSS: 100.

INDICATIONS
This patient has a previous history of perforated diverticulitis with peritonitis. He was treated with colectomy with colostomy and after resolution of his inflammation and resumption of a normal good health, he requested colostomy takedown. Preoperative barium enema demonstrated a normal rectum. It did show a few diverticula in the descending colon just proximal to the colostomy. I offered colostomy takedown. Risks including bleeding, infection, injury to intra-abdominal organs, anastomotic disruption potentially requiring further surgery, hernias and wound complications including infections, as well as risks of anesthesia, were discussed with the patient. His questions were answered.

OPERATIVE PROCEDURE
The patient was identified having undergone a mechanical bowel prep. He received intravenous antibiotics and Entereg preoperatively. He was brought to the operating room and placed in the supine position. General endotracheal anesthesia was administered. The Foley catheter was inserted without difficulties. The left lower quadrant colostomy was pursestring closed with 2-0 silk suture. The patient was then placed in a modified lithotomy position with appropriate padding to pressure points. Rigid proctoscopy to a distance of 15 cm demonstrated no disease in the rectum. The rectum was irrigated with Betadine solution.

The abdomen was prepped with ChloraPrep and Ioban drape was used to keep the colostomy wound out of the operative field. Midline laparotomy incision was reopened. Subcutaneous dissection was performed. Rectus fascia was incised, and sharp dissection was used to enter the peritoneal cavity. A paucity of adhesions of the anterior abdominal wall were identified and were taken down using sharp dissection. The Bookwalter retractor was used for exposure. Dissection into the pelvis demonstrated some scarring over the distal colonic stump. I decided to take this down onto the rectum to facilitate better manipulation and anastomosis. I used blunt dissection to create a window in the mesentery of the rectum just below the colorectal junction, and I transected the rectum in this location using the universal stapling device and a blue load. The mesentery to the distal sigmoid colon and rectum were taken down using the harmonic scalpel. The specimen was sent from the field.

I then turned my attention to the colostomy, starting within the abdominal cavity and using a combination of sharp dissection, electrocautery and blunt dissection, I mobilized the colon as it inserted through the abdominal wall. Once I had achieved adequate dissection in this location, I went to the abdominal wall itself and used electrocautery to carve out the colostomy in the adjacent margin of skin. I continued my dissection down to the subcutaneous space, and I was ultimately able to circumferentially dissect free the colostomy and reduce it into the abdominal cavity.

There were some diverticular changes, just proximal to the colostomy, and I felt that these needed to be resected. To achieve this without tension on the anastomosis, I felt compelled to takedown the splenic flexure. So starting at the left colon and moving my way up towards the spleen, I mobilized the lateral avascular adhesions along the white line of Toldt. I then turned my attention to the transverse colon and elevated the mesocolon off the transverse colon. I continued working both from the transverse colon and the descending colon. I was ultimately able to make way around the flexure using mostly blunt dissection and electrocautery to mobilize the colon.

Having thus done so, I transected the colon just proximal to this area of residual diverticular disease using a pursestring clamp. I took the mesentery with white loads with a stapling device. Through this pursestring clamp, the anvil from a 31 mm EEA stapler was passed and secured. I then personally went to the pelvis. Serially dilating the anus, I passed a 31 mm EEA stapler up through the anus to the rectal staple line. Spike was extruded through the staple line. Spike and anvil were married, and a colorectal anastomosis was created. Inspection of the anastomosis with the rigid proctoscope demonstrated no evidence of leakage or bleeding.

The wound was irrigated with saline until the effluent was clear. I closed the colostomy site with 2 layers. First, the deep layer with 0 Vicryl figure-of-eight sutures in a transverse fashion, reapproximating the posterior rectus sheath. A second layer was also figure-of eight 0 Vicryl sutures in a vertical fashion, also reapproximated the anterior rectus sheath.

The rectus fascia in the midline was reapproximated with continuous 0 loop PDS. The wound was irrigated with saline. The skin was closed with staples. Then 3-0 nylon sutures were placed into the colostomy wound for purposes of delayed primary closure. The wound was packed open with saline moistened gauze. Dry dressings were applied. The patient tolerated the procedure well without complication.


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## jdibble (May 3, 2013)

Since the note states this was a colorectal anastomosis, I would use code 44626 instead of 44625. 

*44626* 

_A surgeon closes a previously-existing enterostomy, or a surgically created opening, in the large or small intestine. This code includes both resection of the intestine and a colorectal anastomosis, or a reconnection of the colon and rectum._ 

*44625 * 

_The physician takes down an enterostomy (stoma) of small intestine or colon, with resection and anastomosis other than colorectal. The stoma is resected and an anastomosis between the bowel ends is completed. The physician makes an incision around the stoma or a separate abdominal incision may be made. Next, the stoma is mobilized and taken down from the abdominal wall. The stoma is resected and the bowel ends are reapproximated with staples or sutures. The abdominal incisions are closed. Report 44625 if with resection and anastomosis other than colorectal. _

That's the way I read this...any other opinions?

Thanks,


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## hcg (May 3, 2013)

*Thank you*



jdibble said:


> Since the note states this was a colorectal anastomosis, I would use code 44626 instead of 44625.
> 
> *44626*
> 
> ...





A very good explanation. It made me understand more on the two codes since I was confused. Thank you much Jodi. I really appreciate for taking time on this op report


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