I am trying to code this surgery and I am having some difficulty on where to start. Any suggestions would be helpful.
The patient went to the OR on May 8, 2015 in order to have her robotic-assisted laparoscopic right radical cystectomy, robotic-assisted laparoscopic sacrospinous vaginal vault suspension, robotic-assisted laparoscopic bilateral extended pelvic lymph node dissection, open ileoconduit creation and bilateral open ureteral stent placement. She got all these surgery for bladder cancer and right obstructive uropathy.
I was consulted four days ago secondary to massive ileus that she has developed with a very high output through the nasogastric tube that actually was replaced, started working adequately and she started feeling much better, so we thought that she might be having ileus since she did not resolve in the next three to four days. CAT scan was obtained. There was an evidence of collection on the pelvis with the same transition point that was very close to the distal ileum. There was a concern of this being secondary to an issue of the jejunojejunostomy. She also had some fluid in the pelvis. Since she did not get better and she started spiking some fever, I decided to take her to the OR in order to perform the following procedure; exploratory laparotomy, lysis of adhesions, drainage of a pelvic abscess, revision of the left ureterojejunostomy, meaning connection of the left ureter to the conduit, also excision of Meckel diverticulum that was found to be present on the terminal ileum and abdominal washout. A Davol drain number 15 was placed in the pelvic area where I washed out the abscess, an extent into the area where both ureters joined the ileal conduit.
The findings were basically very large pelvic abscess that was soaking in some loop of small bowel creating a transition point, which was not clearly identified, but there was definitely some obstruction secondary to this abscess. There was no obvious source for this abscess. I run the bowel as well as inspect the cecum and the rectosigmoid junction with no evidence of enterotomies. There was a little leak coming out of the ureterojejunostomy on the left side, which I do not know it was created because of the abscess or maybe it was the leading point or the reason of the abscess formation. The right ureter, which was getting into the conduit was all embedded into the abscess cavity. The stent could be palpated in the proximal portion of the ureter, but the whole abscess cavity was surrounding this area. I was able to dissect the abscess cavity, but I kept it surrounding the ureter to avoid any compromise of this structure.
I irrigated the abdomen extensively.
There was an incidental finding of a Meckel diverticulum that was excised at the level of the base with no obvious narrowing of the loop of bowel, this Meckel diverticulum is about 10-15 cm from the ileocecal valve, since there are extra 10 cm in between that are just be used as a conduit.
The anastomosis was inspected. It was a side-to-side anastomosis, patent with no evidence of leak. Anastomosis was intact.
INTRAVENOUS FLUIDS: She received about 2.4 L IV fluids.
URINE OUTPUT: About 200 mL, I milked about 1.1 liter of succus into the nasogastric tube and she bled about probably 100 mL. That was not a real bleeding, which is coming from the murky fluid and the raw surface on the area of the abscess down in the pelvis.
I placed the rectosigmoid junction on the pelvic inlet, so no small bowel loop could get in there and create the small bowel obstruction. I also closed the abdomen using some sheaths of Seprafilm to decrease the amount of adhesions on Ms. Csicsila.
PROCEDURE NARRATIVE: The patient was taken to the operating room, placed in supine position. Adequate sedation, anesthesia was induced with no problem and she became intubated without any issues. I proceeded to prep and drape the patient in surgical fashion including the bag that was covering the ileal conduit. I removed the staples and opened the wound with some pressure. There was not any problem. The PDS was _____ and I was able to get into abdominal cavity without any problem. Very careful blunt dissection of all these dilated loop of bowel that was severely adhered to each other as well as abdominal wall was done, being able to identify an abscess going all the way down in the pelvis_____ the distal ileum and creating a transition point. This abscess was actually involving in several loops of small bowel, was deep in the pelvis and as I said before, I could not find any evident source for this abscess. There was no evidence of enterotomies on the cecum, on the rectosigmoid junction or the small bowel. As I said before, the right ureter anastomosis towards the conduit was all embedded in the abscess capsule and the left one had a little leak that maybe was created secondary to the abscess and a little tension that it placed on the area, regardless, I just revised this anastomosis with 5-0 PDS, basically reinforcing the anastomosis, keeping the stent in of course and making sure the ureter remains patent. About five 5-0 PDS were placed to reinforce this anastomosis.
I evacuated the abscess and irrigated profusely, placed a number 15 Blake drain as I previously mentioned. Also, by mobilization of small bowel, I was able to identify Meckel diverticulum, small, which did not have any evidence of inflammation, but I decided just to transect it at the level of the base with a blue load GIA 60. There was no evidence of narrowing of the small bowel loop. As I said before, the jejunojejunostomy was also inspected and was completely patent with no evidence of leak. There was an antimesenteric anastomosis side-to-side, which was very nicely done.
I irrigated the area profusely around the bowel from the terminal ileum all the way to the ligament of Treitz obtaining about 1.1 L of succus through the nasogastric tube.
I proceeded then to place the bowel in order leaving this rectosigmoid junction down into the pelvis, kind of occluding the cavity, so I avoid any loop of small bowel to go in that area and create another small bowel obstruction. I placed some Seprafilm on top of small bowel and closed the fascia with a loop PDS starting from each corner and meeting on the center. The wound was loosely approximated on top of a thin Penrose. At the end of the procedure, of course before I closed, I inspected and confirmed the adequate location of the nasogastric tube. At the end of procedure, she was safely extubated and transferred to recovery in stable condition.
____________________
The patient went to the OR on May 8, 2015 in order to have her robotic-assisted laparoscopic right radical cystectomy, robotic-assisted laparoscopic sacrospinous vaginal vault suspension, robotic-assisted laparoscopic bilateral extended pelvic lymph node dissection, open ileoconduit creation and bilateral open ureteral stent placement. She got all these surgery for bladder cancer and right obstructive uropathy.
I was consulted four days ago secondary to massive ileus that she has developed with a very high output through the nasogastric tube that actually was replaced, started working adequately and she started feeling much better, so we thought that she might be having ileus since she did not resolve in the next three to four days. CAT scan was obtained. There was an evidence of collection on the pelvis with the same transition point that was very close to the distal ileum. There was a concern of this being secondary to an issue of the jejunojejunostomy. She also had some fluid in the pelvis. Since she did not get better and she started spiking some fever, I decided to take her to the OR in order to perform the following procedure; exploratory laparotomy, lysis of adhesions, drainage of a pelvic abscess, revision of the left ureterojejunostomy, meaning connection of the left ureter to the conduit, also excision of Meckel diverticulum that was found to be present on the terminal ileum and abdominal washout. A Davol drain number 15 was placed in the pelvic area where I washed out the abscess, an extent into the area where both ureters joined the ileal conduit.
The findings were basically very large pelvic abscess that was soaking in some loop of small bowel creating a transition point, which was not clearly identified, but there was definitely some obstruction secondary to this abscess. There was no obvious source for this abscess. I run the bowel as well as inspect the cecum and the rectosigmoid junction with no evidence of enterotomies. There was a little leak coming out of the ureterojejunostomy on the left side, which I do not know it was created because of the abscess or maybe it was the leading point or the reason of the abscess formation. The right ureter, which was getting into the conduit was all embedded into the abscess cavity. The stent could be palpated in the proximal portion of the ureter, but the whole abscess cavity was surrounding this area. I was able to dissect the abscess cavity, but I kept it surrounding the ureter to avoid any compromise of this structure.
I irrigated the abdomen extensively.
There was an incidental finding of a Meckel diverticulum that was excised at the level of the base with no obvious narrowing of the loop of bowel, this Meckel diverticulum is about 10-15 cm from the ileocecal valve, since there are extra 10 cm in between that are just be used as a conduit.
The anastomosis was inspected. It was a side-to-side anastomosis, patent with no evidence of leak. Anastomosis was intact.
INTRAVENOUS FLUIDS: She received about 2.4 L IV fluids.
URINE OUTPUT: About 200 mL, I milked about 1.1 liter of succus into the nasogastric tube and she bled about probably 100 mL. That was not a real bleeding, which is coming from the murky fluid and the raw surface on the area of the abscess down in the pelvis.
I placed the rectosigmoid junction on the pelvic inlet, so no small bowel loop could get in there and create the small bowel obstruction. I also closed the abdomen using some sheaths of Seprafilm to decrease the amount of adhesions on Ms. Csicsila.
PROCEDURE NARRATIVE: The patient was taken to the operating room, placed in supine position. Adequate sedation, anesthesia was induced with no problem and she became intubated without any issues. I proceeded to prep and drape the patient in surgical fashion including the bag that was covering the ileal conduit. I removed the staples and opened the wound with some pressure. There was not any problem. The PDS was _____ and I was able to get into abdominal cavity without any problem. Very careful blunt dissection of all these dilated loop of bowel that was severely adhered to each other as well as abdominal wall was done, being able to identify an abscess going all the way down in the pelvis_____ the distal ileum and creating a transition point. This abscess was actually involving in several loops of small bowel, was deep in the pelvis and as I said before, I could not find any evident source for this abscess. There was no evidence of enterotomies on the cecum, on the rectosigmoid junction or the small bowel. As I said before, the right ureter anastomosis towards the conduit was all embedded in the abscess capsule and the left one had a little leak that maybe was created secondary to the abscess and a little tension that it placed on the area, regardless, I just revised this anastomosis with 5-0 PDS, basically reinforcing the anastomosis, keeping the stent in of course and making sure the ureter remains patent. About five 5-0 PDS were placed to reinforce this anastomosis.
I evacuated the abscess and irrigated profusely, placed a number 15 Blake drain as I previously mentioned. Also, by mobilization of small bowel, I was able to identify Meckel diverticulum, small, which did not have any evidence of inflammation, but I decided just to transect it at the level of the base with a blue load GIA 60. There was no evidence of narrowing of the small bowel loop. As I said before, the jejunojejunostomy was also inspected and was completely patent with no evidence of leak. There was an antimesenteric anastomosis side-to-side, which was very nicely done.
I irrigated the area profusely around the bowel from the terminal ileum all the way to the ligament of Treitz obtaining about 1.1 L of succus through the nasogastric tube.
I proceeded then to place the bowel in order leaving this rectosigmoid junction down into the pelvis, kind of occluding the cavity, so I avoid any loop of small bowel to go in that area and create another small bowel obstruction. I placed some Seprafilm on top of small bowel and closed the fascia with a loop PDS starting from each corner and meeting on the center. The wound was loosely approximated on top of a thin Penrose. At the end of the procedure, of course before I closed, I inspected and confirmed the adequate location of the nasogastric tube. At the end of procedure, she was safely extubated and transferred to recovery in stable condition.
____________________