# Descending Colon Resection and Transverse Colostomy



## sctaylor (Jan 28, 2013)

I am new with General Surgery and need a little guidance with this op note.

I am unsure if 44141 or 44143 would be appropriate.  Thank you!

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PROCEDURE:
Exploratory laparotomy, lysis of adhesions, descending colon resection and transverse colostomy.  

BLOOD LOSS
250.

ANESTHESIA:
General endotracheal.

COMPLICATIONS:
None evident.  

Starting Hct 22 and the patient received 1 unit of blood to avoid pressor requirements.

WOUND CLASSIFICATION:
Contaminated.

SURGERY TYPE:
Urgent.

INDICATIONS:
This is a 64-year-old woman who has a history of a prior sigmoid resection for inflammatory changes that had been presumed to be diverticulitis although the final pathology was consistent with ischemic colitis.  She had developed a stricture in the descending portion of her colon over the years; however, this was asymptomatic until a few months ago when after a bout of sepsis and pneumonia, the inflammation in her left colon became much worse and the strictures were not traversable via a scope. Due to the chronic colonic obstruction and dependence to narcotics, she had intermittent episodes of admission for these symptoms.  Over the past 2 months, she has had 2 admissions, which on CT scan also demonstrated concern for distal small-bowel obstruction related to adhesions.  Ultimately it was decided that due to her frequent hospitalizations she would be taken to the operating room for definitive management.

DESCRIPTION OF PROCEDURE:
She was greeted in the preoperative area, site was marked and questions answered.  In the operating room, general anesthesia was induced and she was intubated.  Her abdomen was prepped and draped.  A midline celiotomy was performed which had to be extended to about 5 cm from the xiphoid all the way down to the pubis to get adequate exposure.  Upon entry into the abdomen, omentum was tenaciously adhesed against the anterior abdominal wall and was peeled back with a combination of scissor work and cautery.  Due to the amount of chronic inflammation in her abdomen, her tissues were quite edematous and hyperemic which did cause mild oozing throughout the case.  Surgical bleeding was controlled with cautery and/or ties where necessary.  A portion of the omentum stuck to the left abdomen was particularly edematous and had the appearance of the mass.  This portion was resected and sent for permanent as well as for frozen section which came back with inflammatory changes and no malignancy.  We then proceeded to remove the small bowel adhesions to the overlying omentum and then perform lysis of adhesions from the ligament of Treitz down to the ileocecal valve. We found 2 loops in the pelvis near the ileocecal valve that appeared to be possibly the source of the obstruction although the caliber of the bowel was not appreciably different from proximal to distal.  All of the small bowel did have a whitish discoloration that appeared to be related to chronic ischemia and was reminiscent of radiation changes.  There were no other abnormalities in the bowel and the lumen was not narrowed or strictured in any portion; in fact it was diffusely dilated and floppy.  We then followed the right colon to the transverse which was all normal down to the area of the descending colon where there was approximately 15 to 20 cm of strictured colon which was very, very thick walled and edematous in this area.  We started by taking the attachments of the colon to the abdominal side wall down and trying to come around the colon from the lateral side.  Once we were able to do that distally, we were able to encircle the colon and get a sense of its dimensions.  Once we had that we continued with our cephalad dissection to the splenic flexure, taking down the colon and its attachments from the omentum and the omental attachments to the colonic mesentery.  Once the left side of the colon was completely freed, we were able to then find an area of the transverse colon that appeared healthy without any strictures or edema and at this point we decided to come across the colon with a 55 blue stapler.  With this portion resected, we used it as our guide to continue our medial and inferior dissection taking the blood vessels, the mesentery and related tissue between ties and continuing to peel the colon down all the way.  We took specific care to stay close to the colon, so that the nerves and vessels and/or ureter would stay toward the floor.  Once we came through the known strictured portion to the upper rectum which was soft and normal, we were then able to come across the specimen again with a 55 blue GIA and the specimen was sent back to pathology for analysis.  The abdomen was then thoroughly irrigated.  The rectal stump was identified.  The staple line was inspected and found to be satisfactory and we placed a Prolene stitch to mark the rectum for possible colostomy reversal in the future.  Once the abdomen was thoroughly irrigated, we again ran the bowel from ligament of Treitz to ileocecal valve, ensuring that there were no other concerns.  The omentum was laid back down over the small bowel and the celiotomy approximated with 2 looped O PDS that were tied in the middle.  The skin was approximated with staples.  Prior to closure, we took a small disk of skin approximately 1.5 cm in diameter just above and to the left of the umbilicus in the center of the rectus muscle.  Subcutaneous tissues were then bovied until the anterior rectus sheath was seen.  This was incised up and down for a distance of about 2 cm and the muscle identified. The muscle was retracted and the posterior rectus sheath was incised as well.  This ostomy site was expanded to allow the transverse colon to come freely without tension and was held in place with a Babcock.  We then closed the abdomen, applied staples and then the ostomy was matured after first excising the staple line and then by taking full thickness bites through the colon and attaching it to the dermis with 3-0 Vicryl circumferentially.   Once the ostomy was adequately matured, it was inspected.  The mucosa of the colon was slightly hyperemic with mild signs of mucosal ischemia but was essentially viable with good bleeding at the edges.  An ostomy bag was then placed over the ostomy.  The patient was awoken from anesthesia, extubated and brought to the recovery area in stable condition.


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## MCook (Feb 3, 2013)

A colostomy was created so 44143 would be more appropriate. I am seeing the rectal stump involved so I am questioning if 44146 would be the most appropriate code.  I will be interested in other input.


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