I don't have much experience with urology, and could use some help finding the correct anesthesia CPT for the procedure documented below.
PREOPERATIVE DIAGNOSIS:
Neurogenic bladder with urinary incontinence.
POSTOPERATIVE DIAGNOSIS:
Neurogenic bladder with urinary incontinence.
OPERATION PERFORMED:
Ileal loop urinary diversion.
DESCRIPTION OF PROCEDURE:
The patient was taken back to the operating room in good and stable condition and underwent general endotracheal anesthetic without difficulty. The region of the abdomen was sterilely prepped and draped in the usual fashion. The patient was placed in the supine position. The abdomen was sterilely prepped and draped. A midline incision was then performed going from the pubis up to the left of the umbilicus and approximately 2 cm above the umbilicus. This was dissected down to the anterior rectus sheath which was incised in the midline. The abdomen was entered in the midline without difficulty. Having entered the abdomen, our attention was now turned to complete exploration of the abdomen and lysis of adhesions that existed. The Bookwalter retractor was then placed which allowed good exposure. The right ureter was identified as it went over the common iliac and this was carefully dissected down all the way to the region where it went underneath the obliterated umbilical artery. The artery was ligated proximally, distally, and cut. The ureter was then cut as it entered the intramural ureter. It was ligated with a 0 stick-tie distally and proximally first. The same was then performed on the left and the ureter was completely freed up on the left without difficulty. Subsequently, the left ureter was brought through the retroperitoneum over to the right side without difficulty. Hemostasis was confirmed on the left and right in the pelvis. Subsequently, the bowels were then completely inspected and run. The ileum was identified. A segment of ileum approximately 12 cm in length was then used, approximately 15 cm from the ileocecal junction. This segment was freed with its mesentery by carefully maintaining blood flow to this region. Having freed up the ileum at its mesentery, the bowel was then reconnected superior to the ileal loop in a classic side-to-side fashion using a GIA stapler and then subsequently closing the end with a TA stapler. All suture lines were then oversewn, inverting the staples inward using 3-0 silk sutures. The mesenteric defect was then closed with interrupted 3-0 silk sutures. The distal end of left and right ureter were then sutured to the proximal end of the ileal loop in a classic end-to-side fashion spatulating the ureters for approximately 2 cm and then removing a segment of the serosa of the distal ileum and opening up the mucosal surface as well. A mucosal-to-mucosal anastomosis was then used using 4-0 Monocryl interrupted sutures. The serosa was then sutured to the serosa using interrupted 2-0 Monocryl sutures. The anastomoses on the right and left were stented using 7-French urinary diversion stents without difficulty. Having completed the ileal loop urinary diversion, the ileum was then brought up to a predetermined spot in the anterior abdominal wall over the right, through the rectus muscle. The anterior rectus sheath was scored and subsequently the ileal loop was brought up through the rectus muscles to the anterior abdominal wall. The ileal loop was sutured to the anterior rectus sheath using interrupted 0 Vicryl sutures x3. The ileal loop was then matured
using 2-0 Vicryl sutures in a classic rosebud fashion. Having completed the
above, there was an excellent rosebud and cosmetic result. There was no
tension on the mesentery. Both ureters were stented and draining well. The
abdomen was completely inspected. Instrument and lap counts were all correct. The abdomen was then closed with a running #1 PDS and the skin was reapproximated with staples. The patient tolerated the above.
COMPLICATIONS:
None.
CONDITION:
Stable.
DRAINS:
Include a 10-French JP drain and two 7-French urinary diversion stents.
Of note, a cystectomy was not performed. It was simply an ileal loop urinary
diversion.
PREOPERATIVE DIAGNOSIS:
Neurogenic bladder with urinary incontinence.
POSTOPERATIVE DIAGNOSIS:
Neurogenic bladder with urinary incontinence.
OPERATION PERFORMED:
Ileal loop urinary diversion.
DESCRIPTION OF PROCEDURE:
The patient was taken back to the operating room in good and stable condition and underwent general endotracheal anesthetic without difficulty. The region of the abdomen was sterilely prepped and draped in the usual fashion. The patient was placed in the supine position. The abdomen was sterilely prepped and draped. A midline incision was then performed going from the pubis up to the left of the umbilicus and approximately 2 cm above the umbilicus. This was dissected down to the anterior rectus sheath which was incised in the midline. The abdomen was entered in the midline without difficulty. Having entered the abdomen, our attention was now turned to complete exploration of the abdomen and lysis of adhesions that existed. The Bookwalter retractor was then placed which allowed good exposure. The right ureter was identified as it went over the common iliac and this was carefully dissected down all the way to the region where it went underneath the obliterated umbilical artery. The artery was ligated proximally, distally, and cut. The ureter was then cut as it entered the intramural ureter. It was ligated with a 0 stick-tie distally and proximally first. The same was then performed on the left and the ureter was completely freed up on the left without difficulty. Subsequently, the left ureter was brought through the retroperitoneum over to the right side without difficulty. Hemostasis was confirmed on the left and right in the pelvis. Subsequently, the bowels were then completely inspected and run. The ileum was identified. A segment of ileum approximately 12 cm in length was then used, approximately 15 cm from the ileocecal junction. This segment was freed with its mesentery by carefully maintaining blood flow to this region. Having freed up the ileum at its mesentery, the bowel was then reconnected superior to the ileal loop in a classic side-to-side fashion using a GIA stapler and then subsequently closing the end with a TA stapler. All suture lines were then oversewn, inverting the staples inward using 3-0 silk sutures. The mesenteric defect was then closed with interrupted 3-0 silk sutures. The distal end of left and right ureter were then sutured to the proximal end of the ileal loop in a classic end-to-side fashion spatulating the ureters for approximately 2 cm and then removing a segment of the serosa of the distal ileum and opening up the mucosal surface as well. A mucosal-to-mucosal anastomosis was then used using 4-0 Monocryl interrupted sutures. The serosa was then sutured to the serosa using interrupted 2-0 Monocryl sutures. The anastomoses on the right and left were stented using 7-French urinary diversion stents without difficulty. Having completed the ileal loop urinary diversion, the ileum was then brought up to a predetermined spot in the anterior abdominal wall over the right, through the rectus muscle. The anterior rectus sheath was scored and subsequently the ileal loop was brought up through the rectus muscles to the anterior abdominal wall. The ileal loop was sutured to the anterior rectus sheath using interrupted 0 Vicryl sutures x3. The ileal loop was then matured
using 2-0 Vicryl sutures in a classic rosebud fashion. Having completed the
above, there was an excellent rosebud and cosmetic result. There was no
tension on the mesentery. Both ureters were stented and draining well. The
abdomen was completely inspected. Instrument and lap counts were all correct. The abdomen was then closed with a running #1 PDS and the skin was reapproximated with staples. The patient tolerated the above.
COMPLICATIONS:
None.
CONDITION:
Stable.
DRAINS:
Include a 10-French JP drain and two 7-French urinary diversion stents.
Of note, a cystectomy was not performed. It was simply an ileal loop urinary
diversion.