# Could use help with this one



## rkindlund (May 6, 2015)

I can code the hemicolectomy. Would you use 47001 or 47100 for the liver biopsy? And any help on the biopsy of peritoneal implants would be appreciated.


PREOPERATIVE DIAGNOSIS:  Right colon carcinoid tumor with questionable liver 
implant and peritoneal implants.

POSTOPERATIVE DIAGNOSIS:  Right colon carcinoid tumor with questionable liver 
implant and peritoneal implants.

PROCEDURE:  Right open hemicolectomy and liver biopsy and biopsy of peritoneal 
implants


SPECIMENS:
1.  Right colon and small bowel.
2.  Liver biopsy.
3.  He is peritoneal implants biopsies.

FINDINGS:  Significant carcinoid tumor burden of the right colon with extensive 
adhesion of the right colon to the right pelvic sidewall and retroperitoneum 
which had to be excised en bloc.  57 inches of small bowel was resected in 
addition to the right colon secondary to peritoneal studding and mesenteric 
studding and ileal thickening.  57 inches of bowel was removed and the remaining
small bowel was measured to be 118 inches, adequate for digestion.

INDICATION FOR PROCEDURE:  This is a 78-year-old female who presented with 
signs, symptoms, and diagnostic studies consistent with right carcinoid of the 
colon.  Risks and benefits were explained to the patient.  Informed consent was 
obtained.

The patient was brought to the operating room, placed on the table in supine 
position.  After successful general anesthesia was induced, the abdomen was 
prepped and draped in the usual sterile fashion.  Initially anesthetized the 
midline incision with 0.25% Marcaine, made a vertical midline incision starting 
above the umbilicus and extending just below the umbilicus, dissected down 
through skin and subcutaneous tissues to the level of the fascia.  The fascia 
was elevated and incised ____ the incision gained entry into the abdomen and  
serous serous fluid was evacuated.  Upon gross palpation, there was a large 
bulky mass with bulky lymphadenopathy of the right colon and mesenteric region. 
A self-retaining retractor was placed.  I used Bovie cautery to incise the 
peritoneum and proceeded to mobilize the right pelvic sidewall to detach the 
right colon from the retroperitoneum.  The peritoneum was also included in the 
specimen and was able to mobilize medially and free up the attachments.  I was 
able to mobilize the mesentery of the right colon to isolate out the ileocolic 
vessels, which were ligated with a vascular stapler.  Right branch of the right 
middle colic was also ligated with a vascular stapler.  I then proceeded to 
divide the transverse colon at the area that was a safe distance from the right 
colon mass.  ____ the right branch of the middle colic artery.  This was divided
with a GIA-75 mm stapler.  I then proceeded to examine very extensively the 
ileum and there was significant amount of at least 15 to 20 cm of distal ileum 
that had direct involvement of carcinoid tumor with thickening and studding and 
also extending into the mesentery.  I identified a location approximately distal
55 inches of small bowel and identified a transection point by creating a hole 
in the mesentery dividing the bowel with a GIA-75 mm stapler and using a 
LigaSure to ligate the rest of the mesentery.  

The specimen was passed off.  I then proceeded to examine and noticed that there
were peritoneal studding and attachments, peritoneal implants, that were 
biopsied off the liver that was sent off as specimen and hemostasis was achieved
with Bovie cautery and Surgicel was placed in the biopsy sites.  There were also
some right peritoneal studding and this peritoneum was excised.  On palpation, 
there was extensive amount of peritoneal studding along the anterior abdominal 
wall, deep into the pouch of Douglas and into the pelvis and much of that 
peritoneum was removed and sent as peritoneal biopsies.  There were a couple/few
mesenteric studding masses that were removed and sent off as biopsy.  I then 
proceeded to do a side-to-side functional and ileocolic anastomosis aligning the bowels with 3-0 silk and then firing a 75 mm stapler across the 2 limbs of the bowel, creating a nice patent anastomosis.  The resulting defect was closed with running 0 Vicryl and reinforced with 3-0 silk Lembert stitches.  The mesenteric defect was reapproximated with 3-0 silk figure-of-eight stitches and placed back in proper orientation then irrigated the abdomen with copious amounts of normal saline until the suction effluent was clear, removed my self-retaining retractors and closed the midline incision with #1 PDS and the skin was closed with staples.  Antibiotic cream and sterile dressing was applied.  The patient tolerated the procedure well, was awoken and taken to recovery room in stable condition.


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## klbajus (May 7, 2015)

I would use 47001


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