# Colectomy with Splenic Flexure Mobilization



## talitha82 (Apr 8, 2014)

I have having trouble with this case, and as I am not as atune to Gastro coding, I think my lack of knowledge might be keeping me from choosing the correct codes here. All I see that I can code on this one is 44143. The splenic flexure was done laparoscopically, so I can't code 44139, can I?


PREOPERATIVE DIAGNOSIS: Sigmoid colon cancer.
POSTOPERATIVE DIAGNOSIS: Sigmoid colon cancer.
PROCEDURES PERFORMED:
1. Laparoscopy.
2. Laparoscopic splenic flexure mobilization.
3. Open low anterior resection, segmental colon resection with end colostomy.
4. Hartmann's procedure with rectal pouch.

DESCRIPTION OF FINDINGS:
1. Intraabdominal adhesions.
2. Intrapelvic adhesions.
3. Sigmoid colon mass with local extension of tumor into adjacent distal sigmoid colon, adherence to
pelvic sidewall, and urinary bladder.

DESCRIPTION OF PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to the major operating suite, where she was placed supine on the operating table. Monitors were placed, and bony prominences were padded. The patient received intravenous antibiotics within 1 hour of incision time. The patient was placed supine on the operating table. Monitors were placed. Bony prominences were padded. Pneumatic sequential compression hose were activated. The patient was induced under excellent general endotracheal anesthesia. Foley catheter was placed. The patient was placed in stirrups and low lithotomy position. Perineum was prepped with Betadine. Abdomen was prepped with ChloraPrep. She was draped appropriately. Aseptic technique was used. Surgical timeout was performed.

Supraumbilical incision was made. Fascia was incised. Abdomen was entered sharply. Hasson trocar was placed, insufflating the abdomen to 15 tor CO2 gas. Subsequently three 5 mm trocars were placed in the left upper quadrant, left lower quadrant, and suprapubic region. Patient was placed in the Trendelenburg position. Adhesions were encountered. Great care was exercised during  placement of trocars, and subsequent placement of instruments to avoid injury to underlying structures. Harmonic scalpel was used to take down the
adhesions to the anterior abdominal wall. The tumor was identified. It was a relatively fixed mass in the pelvis. Attention was directed to the lateral sidewall on the patient's left side, as well as splenic flexure. The patient was placed in reverse Trendelenburg position. Splenic flexure was taken down with harmonic
scalpel. Ureter was identified and left unmolested. Avascular white line of Toldt was taken down. The patient was then placed in Trendelenburg once again in evaluation of mobilization of the tumor from pelvis sidewall. It appeared densely adherent to the urinary bladder, extending to the base of the urinary
bladder. Because of this extensive adherence, it was felt to be more safe to convert to an open procedure. Insufflation was evacuated. Trocars and instruments were removed. A low midline incision was made. Sigmoid colon mass was mobilized. There was gross extension of tumor through the sigmoid wall, the more proximal sigmoid colon, and with growth into the wall of more distal sigmoid colon. Urinary bladder was densely adherent to the tumor mass. The tumor mass peeled off the urinary bladder. The urinary bladder had no gross tumor left behind; however, the bladder was quite indurated. Of note, the
left ureter was closely adherent to the mass and in the region of the indurated portion of the urinary bladder. Small bowel was run from ligamentum Treitz to the ileocecal valve. There were no masses identified. Remainder of colon was without mass lesion. Mesentery was without gross disease. Distal descending colon was divided with GIA stapling device. Mesocolon was taken down, selectively doubly tying and ligating the mesocolonic vessels selectively with great care to avoid injury to ureters.

Rectum was mobilized below the peritoneal reflection, and GIA stapling device was used to divide the rectum at this level, freeing the tumor and segment of distal sigmoid colon. This was sent to pathology for permanent section. Ureter was inspected. It appeared intact. Due to the marked inflammatory response baseline malnutrition and notation of direct extension of tumor, it did not appear to be a safe environment in which to create a low anterior anastomosis. Therefore, end colostomy was performed. A site was selected on the anterior abdominal wall. Her ostomy circular skin segment was removed from
the left mid-abdomen. Cruciate incision was made in the abdominal wall fascia. End colostomy was developed. Distal descending colon was externalized through this ostomy site without constriction. Segment of bowel was secured to the abdominal fascia with interrupted 3-0 silk suture. Abdomen and
pelvis was irrigated. Irrigation was extracted. The fascia was closed with #1 looped PDS. Skin was closed with staples. Attention was then directed to maturation of ostomy. Ostomy was matured utilizing 3-0 Vicryl suture and 3-0 silk. Once matured, the ostomy was tested for patency.

Patency was ascertained and ostomy appliance was applied. Of note, prior made trocar sites were closed with skin staples. Fascia at the supraumbilical site was closed with 0 Vicryl. Sterile dressings were applied. The patient tolerated the
procedure well. There were no evident complications.


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## jroxas (Apr 8, 2014)

*Lap splenic flexure mobilization*

Hi
Use 44213, laparoscopic surgical mobilization of splenic flexure and 44143, open Hartmann procedure. Other procedures such as adhesiolysis are bundled
Jerry E. Roxas, CPC


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## talitha82 (Apr 8, 2014)

jroxas said:


> Hi
> Use 44213, laparoscopic surgical mobilization of splenic flexure and 44143, open Hartmann procedure. Other procedures such as adhesiolysis are bundled
> Jerry E. Roxas, CPC



That is what I was initially going to choose, but when I checked the edits, those two are bundled and are not even allowed with a modifier.


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