# Laparascopic low anterior resection end colostomy



## R1CPC (Mar 10, 2015)

44208 vs 44206 or ???

DESCRIPTION OF PROCEDURE:  The patient was brought to operating room and placed
in the supine position under general anesthesia and intubated.  The patient's
abdomen was prepped and draped in sterile fashion and placed in low lithotomy
and a final time out was done.  Preoperative antibiotics were given.  A
supraumbilical incision was made.  Needle inserted, the abdomen insufflated to
50 mm of CO2 and then the 12 mm trocar was placed.  Upon placing the camera, no
intra-abdominal injuries were noted.  Three more trocars were placed, 2 in the
right lower quadrant, 1 in the left lower quadrant.  The patient was then placed
in steep Trendelenburg.  I began my dissection lateral to medially, visualizing
the IMA, making a window medially pulling down on the ureter and dissecting the
lateral side wall.  Then a purple Endo-GIA was used to come across the IMA.
Then the mesocolon was lifted from the retroperitoneum and dissected to the
presacral space and the presacral space was entered.  At this point, I decided
to go ahead and take the lateral attachment.  At the lateral attachment the
white line of Toldt was mobilized to the pelvic rim.  There was some
inflammatory areas and incision scar thickening, probably from the radiation.
These were cut down using the Harmonic.  The ureter was kept to the side wall
and it was always inside, never injured.  Then, the presacral space was entered
and dissection was carried all the way down to the levators posteriorly, then
laterally the two sides were connected.  Then, the patient had a history of a
hysterectomy, so the vaginal cuff was separated from the rectum and the rectum
dissection was begun extraperitoneally and distally all the way down to the
levators.  At this point, a snap was placed intra-abdominally and digital rectal
examination was done.  I was right at the anorectum distal to the cancer.  Two
purple Endo-GIs were fired across this.  One purple Endo-GI was fired proximally
and the specimen was completely separated at this point.  There was no active
bleeding.  The pelvis was irrigated.  A JP drain was placed into the pelvis.  A
4 cm incision was then made in the left lower quadrant using cautery and going
through the anterior and posterior fascia the wound protector was introduced and
the specimen was brought out into the field.  I opened the specimen distally and
I had gotten the whole distal aspect of the   tatoo  .  At this point, the
specimen was out, premarked colostomy area was cut down and the descending colon
was brought out.  Then the fascias were closed, 4 cm incision was closed using a
2 layer fashion.  The posterior fascia was closed using 0 Vicryl, anteriorly
with looped 0 PDS.  30 mL of local was injected and then all the skins were
closed and a Brooke colostomy was created using 3-0 Monocryl.  The patient was
awakened, extubated, and sent to PACU in stable condition.


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## cynthiabrown (Mar 10, 2015)

44208


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## R1CPC (Mar 11, 2015)

Encoder says the remaining rectum and colon is anastamosed for CPT 44208 and this report doesnt seem to mention the anastamosis unless I'm missing it???


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## cynthiabrown (Mar 11, 2015)

you're right.............he closed it 44206. Good job!!!


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## R1CPC (Mar 11, 2015)

One more question, I was almost tempted to code this as a protectomy but from your interpretation this wouldnt qualify right??? I'm just not sure if the entire rectum was removed...if it was would we code this differently??


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## cynthiabrown (Mar 12, 2015)

He described stapling so I would say he did not remove rectum. But if he had, it would be a different code for sure


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