# Abdominoperineal Resection



## aguelfi (Apr 30, 2012)

I have a report attacted that I'm debating on the coding with.  The physician performed a complete proctectomy without anastomosis and without pull through because the patient already had an ileostomy.  I debating between 45110-52 mod or 45999 unlisted.  What do others think?  


The operation was begun by placing a laparoscope through a small trocar in
the umbilical region and then exploring the abdominal cavity. We then
placed 2 more trocars on the patients right side and found that there was a
fair amount of tumor load in the pelvis, rendering a laparoscopic approach
suboptimal. We therefore placed a midline incision and placed a Bookwalter
retractor. We then began our dissection by mobilizing the lateral line of
Toldt on the left side and mobilizing the sigmoid and descending colons. We
scored the mesentery on the medial aspect of the sigmoid colon and mobilized
the colon further. We then entered the presacral fascial plane and began
elevating the mesial rectum by blunt dissection in that plane. We
did so very carefully because of the extensive tumor load and the risk of
bleeding that could be encountered in that area. We then continued
dissection laterally as far as possible down to the lateral stalks of the
rectum and we incised the anterior leaf of the peritoneum and dissected the
plane between the bladder and the rectum as far down as possible through
that approach. Once we could no longer dissect any further down the pelvis
because of the we could no longer dissect any further down the pelvis
because of the extensive tumor involvement, we decided that we would
continue the operation from the perineum with the goal of performing a
palliative resection, since the patient had wide locally invasive cancer
with no evidence of metastatic disease and substantial pain from the disease
itself. I therefore placed a perineal incision midway between the anal
opening and the ischial bone on both sides and extended to an elliptical
incision. I carried the incision down to subcutaneous tissue and fat until
I reached the levator muscles. I then took the levator muscles
systematically with the Harmonic Scalpel until I was able to enter the
peritoneal cavity and communicate with my anterior dissection field. We
then continued circumferentially in a systematic manner using the Harmonic
scalpel and blunt dissection until we were able to completely mobilize the
rectum. In the process of doing so, the rectum and the sigmoid separated
and tore at the junction with the tumor, due to our traction and
counter-traction, and we sent the specimen in 2 portions. We then irrigated
the abdominal cavity and the perineum copiously with saline. We closed the
levator muscles with #2 Vicryl sutures in an interrupted manner. We closed
the subcutaneous tissue of the perineum with 2-0 Vicryl suture and then we
closed the skin with surgical staples, we placed a drain from the from above
and drained the pelvis. We irrigated the abdominal cavity copiously with
saline, and then we explored it one more time and found no evidence of
bleeding and no evidence of damage to the ureters, and no evidence of
metastatic disease. We closed the fascia with #2 Vicryl suture. Of note,
the patient had a previous diverting ostomy and therefore a colostomy did
not have to be performed. We had just initially transected the descending
colon past the ostomy at the beginning of the operation.


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## cmartin (Apr 30, 2012)

I would go w/45110-52 unless the carrier is known to automatically use 50% allowances on the -52. You can use the status ileostomy dx code as well as putting the info in the box 19 equivalent-space.


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