Mrsrpc
Guru
Procedure: Colectomy with a take-down of splenic flexure. The patient was taken to the operating room, placed in the dorsal lithotomy position, and then prepped and draped in the usual sterile fashion. A vertical paramedian incision was made along the left side of the umbilicus from the symphysis and taken up to above the umbilicus. This incision was carried down to the rectus muscles, which were separated in the midline. The peritoneal cavity was entered with findings as described. The ascitic fluid was removed and hand-held retractors were used to assist in surgical exposure. The malignant intra-abdominal tumor was resected from the hepatic flexure into the mid transverse colon. The resection was extended into the left upper quadrant and the attachments were also clamped, cut and suture ligated with 2-0 silk sutures in a stepwise fashion until mobilization of the tumor mass could be brought medial and hemostasis was obtained. Attempts to find a dissection plane between the malignant tumor mass and the transverse colon were unsuccessful as it appeared the tumor mass was invading into the wall of the bowel with extrinsic compression and distortion of the bowel lumen. Given the mass could not be resected without removal of bowel, attention was directed to mobilization of the splenic flexure. Retroperitoneal dissection was started in the pelvis and continued along the left paracolic gutter. The ligamentous and peritoneal attachments were taken down with Bovie cautery in a stepwise fashion around the splenic flexure of the colon until the entire left colon was mobilized medially. Similar steps were then carried on the right side as the right colon and hepatic flexure were mobilized. The peritoneal and ligamentous attachments were taken down with Bovie cautery. Vascular attachments were clamped, cut, and suture ligated with 2-0 silk until the right colon was mobilized satisfactorily. The GIA stapler was introduced and fired at both ends to dissect the tumorous bowel free. The bowel was delivered off the operative field. Attention was then directed towards re-anastomosis of the colon. Linen-shod clamps were used to gently clamp the proximal and distal segments of the large bowel. The staple line was removed with Metzenbaum scissors and the colon lumen was irrigated. The silk sutures were used to divide the circumference of the bowel into equal thirds, and the proximal and distal edges of the bowel were reapproximated with silk sutures. The posterior segment of the bowel was then retracted and secured with a TA stapler, ensuring a full thickness bowel wall insertion into the staple line. The additional two-thirds were also isolated and, with the TA stapler, clamped, ensuring that all layers of the bowel wall were incorporated into the anastomosis. A third staple line was fired and the integrity of the anastomosis was checked. First, complete hemostasis was noted. There was well beyond a finger width lumen within the large bowel. The linen-shod clamps were released and gas and bowel fluid were moved through the anastomosis aggressively with intact staple line; no leakage of gas or fluid. The abdomen was then irrigated and water was left over the anastomosis. The anastomosis was manipulated with no extravasation of air. The abdomen and pelvis were then irrigated aggressively. The Mesenteric trap was then re-approximated with interrupted 3-0 silk suture ligatures. All sites were inspected and noted to be hemostatic. Attention was directed towards closing. Pathology report showed intra-abdominal cancer. Transverse colon and hepatic flexure cancer were also indicated. The origin of the cancer could not be determined from the specimen given. What are CPT and ICD10 codes? Why would we report two colectomy codes: 11439 and 11440 if only one true colectomy was performed with a takedown of the hepatic flexure (to keep it from being too tight to reanastamose) and a reanastamosis? Two separate sections of bowel do not appear to have been removed. One piece was resected and "taken off the field". It looks like we are reporting work that was not performed. Next: the tumors resected (though apparently by resecting the same part of the colon) are both coded as primary tumor despite not having any mention of either being primary or secondary "the origin of the cancer could not be deterrmined from the specimen given". I looked at Ch 2 guidelines, but I'm confused by the verbiage. Does it say we treat all tumors like primary if not specified? |
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