Beth Chabot
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I am really stumped regarding coding for Hemicolectomy and resections/anastomosis. 44140 makes sense but when also joining a portion of the large colon with the small colon does 44120 apply? And Gastroepiploic Lymph Nodes? Can you read this note and advise for coding? Any help is appreciated.
OPERATION PERFORMED: 1. Laparoscopic assisted right hemicolectomy. 2. Laparoscopic Cholecystectomy
Surgeon:
FIRST ASSISTANT:
Anesthesia: General
INDICATIONS: Ms. is a 61-year-old female referred by Dr. for biopsy proven right-sided colon cancer. The patient underwent screening colonoscopy and a mass in the right colon was identified. This was biopsied and returned as adenocarcinoma. Options were discussed with the patient and she elected to surgical resection.
PROCEDURE: After obtaining informed consent, she was brought to the operating room and placed supine on the operating table. A time off was performed and the patient and procedure identified. General anesthesia was induced uneventfully. An orogastric tube and Foley catheter were placed and the abdomen was prepped and draped sterilely. We started laparoscopically and a 5-mm supraumbilical incision was made through the skin and subcutaneous tissue. The umbilical stalk was grasped and elevated and using a Veress needle and high flow CO2 pneumoperitoneum was established. A 5-mm trocar was inserted followed by a 5-mm 30 degree laparoscope. The patient had a significant amount of adhesions from her prior surgeries and an additional 5-mm right lower quadrant port as well as a 10-mm midline port about 4 cm above the supraumbilical port was placed. Laparoscopic lysis of adhesions was then undertaken freeing the omentum from the left side of the abdomen in the left upper quadrant and then a significant amount of omental adhesions to the anterior midline in the low midline from her previous GYN surgery. Once we had freed the majority of these adhesions we turned our attention to the right lower quadrant where the colon was identified. It was medialized and elevated. The White line of Toldt was identified and this was incised all the way to the hepatic flexure. There were extensive adhesions of omentum to the liver and gallbladder. These were freed with the harmonic scalpel, but the amount of adhesions to the gallbladder raised the concern for chronic cholecystitis.
I decided to remove the gallbladder rather than risk her having a subsequent gallbladder attack since getting back to this location laparoscopically would be difficult after colectomy and lysis of adhesions. The dome of the gallbladder was grasped and elevated with a Hunter grasper. The infundibulum was given downward and lateral retraction and the peritoneal attachments to the infundibulum were taken down with Maryland dissectors with cautery. The critical view was obtained and the cystic duct and artery were triple clipped and incised. The gallbladder was dissected out of the hepatic fossa using hook cautery. A small posterior cystic artery branch was encountered and triple clipped and incised. Once freed from the liver, the gallbladder was placed in an endopouch and brought out through the 12mm port site and passed off the field as a specimen. The gallbladder fossa was inspected and hemostasis was obtained with cautery. Attention was then returned to mobilization of the colon.
The omentum was freed from the transverse colon by incising the avascular plane with harmonic scalpel and then the hepatic flexure was mobilized with harmonic scalpel and this allowed us to medialize the colon completely. Once we had freed the colon attention was turned back to the pelvis. The ileum had some adhesions in the pelvis from her previous surgery. These were freed laparoscopically using the harmonic scalpel,and then a small laparotomy incision was made in the midline connecting our two midline laparoscopic ports. Ultimately, we had to extend the incision just below the umbilicus in order to free some additional adhesions in the pelvis, but we were able to exteriorize the bowel completely and elevate it. At this point two prominent lymph nodes in the right gastroepiploic region and the greater curvature of the stomach were identified. They were slightly firm. These were a little concerning for metastatic disease and the larger node was excised using harmonic scalpel and sent down for frozen section analysis. This returned negative for malignancy.
An Appropriate area of the terminal ileum was identified. The bowel was separated from its mesentery using Bovie cautery and then staple ligated with a GIA-55 with a blue load. Using a combination of harmonic scalpel, sharp dissection and GIA-55 vascular staple loads the mesentery of the right colon was divided. There were several enlarged nodes at the middle colic vessels. The mass was identified in the proximal transverse colon, several centimeters proximal to the middle colic vessels. But because of the adenopathy in the middle colic mesentery, we decided to take this vessel with our specimen as well. The root of the middle colic vessel as it came off the SMA was identified and separated. There was no adenopathy here. Using a vascular stapler these were staple ligated and then the rest of the transverse colon mesentery was incised. The distal transverse colon was identified. A window was created between the bowel and its mesentery and then using a GIA-75 with a blue load, the bowel was staple ligated in this location. The right colon and most of the transverse colon were then passed off the field as a specimen. The area was copiously irrigated and inspected for hemostasis which was complete. We then turned our attention to recreating bowel continuity.
The ileum and transverse colon were brought alongside each other and secured with 3-0 Vicryl suture. Small enterotomies were made in the antimesenteric portion of the bowel and then using a GIA-75, a stapled side-to-side functional end-to-end anastomosis was created. The resulting enterotomy was closed using a TL-60 stapler and then all staple lines were oversewn with 3-0 Vicryl imbricated as a running Lembert suture. The anastomosis was patent to palpation. It was examined and noted to be without obvious leaks, and then the mesentery was closed using a running 3-0 Vicryl stitch to close down the defect and prevent internal herniation. The abdomen was again irrigated. The bowel was returned to its normal anatomic position. Seprafilm was placed in the abdomen to try and minimize perioperative adhesion formation. Several sheets were placed in the pelvis and the rest were placed just below the fascia. Using looped #1 PDS the fascia was then reapproximated. The knot was buried. Subcutaneous tissue was irrigated.
The midline laparotomy skin was reapproximated using skin staples. The small laparoscopic port sites were closed with 4-0 Monocryl in subcuticular fashion. Sponge, needle and instrument counts were correct at the end of the case. Total fluids were 2200 mL. EBL was estimated at 150 mL. Urine output 200. The orogastric tube was removed. The Foley catheter was left in place at the conclusion of the case. The patient was awakened from anesthesia and transferred to recovery room in stable condition at the conclusion of the operation.
OPERATION PERFORMED: 1. Laparoscopic assisted right hemicolectomy. 2. Laparoscopic Cholecystectomy
Surgeon:
FIRST ASSISTANT:
Anesthesia: General
INDICATIONS: Ms. is a 61-year-old female referred by Dr. for biopsy proven right-sided colon cancer. The patient underwent screening colonoscopy and a mass in the right colon was identified. This was biopsied and returned as adenocarcinoma. Options were discussed with the patient and she elected to surgical resection.
PROCEDURE: After obtaining informed consent, she was brought to the operating room and placed supine on the operating table. A time off was performed and the patient and procedure identified. General anesthesia was induced uneventfully. An orogastric tube and Foley catheter were placed and the abdomen was prepped and draped sterilely. We started laparoscopically and a 5-mm supraumbilical incision was made through the skin and subcutaneous tissue. The umbilical stalk was grasped and elevated and using a Veress needle and high flow CO2 pneumoperitoneum was established. A 5-mm trocar was inserted followed by a 5-mm 30 degree laparoscope. The patient had a significant amount of adhesions from her prior surgeries and an additional 5-mm right lower quadrant port as well as a 10-mm midline port about 4 cm above the supraumbilical port was placed. Laparoscopic lysis of adhesions was then undertaken freeing the omentum from the left side of the abdomen in the left upper quadrant and then a significant amount of omental adhesions to the anterior midline in the low midline from her previous GYN surgery. Once we had freed the majority of these adhesions we turned our attention to the right lower quadrant where the colon was identified. It was medialized and elevated. The White line of Toldt was identified and this was incised all the way to the hepatic flexure. There were extensive adhesions of omentum to the liver and gallbladder. These were freed with the harmonic scalpel, but the amount of adhesions to the gallbladder raised the concern for chronic cholecystitis.
I decided to remove the gallbladder rather than risk her having a subsequent gallbladder attack since getting back to this location laparoscopically would be difficult after colectomy and lysis of adhesions. The dome of the gallbladder was grasped and elevated with a Hunter grasper. The infundibulum was given downward and lateral retraction and the peritoneal attachments to the infundibulum were taken down with Maryland dissectors with cautery. The critical view was obtained and the cystic duct and artery were triple clipped and incised. The gallbladder was dissected out of the hepatic fossa using hook cautery. A small posterior cystic artery branch was encountered and triple clipped and incised. Once freed from the liver, the gallbladder was placed in an endopouch and brought out through the 12mm port site and passed off the field as a specimen. The gallbladder fossa was inspected and hemostasis was obtained with cautery. Attention was then returned to mobilization of the colon.
The omentum was freed from the transverse colon by incising the avascular plane with harmonic scalpel and then the hepatic flexure was mobilized with harmonic scalpel and this allowed us to medialize the colon completely. Once we had freed the colon attention was turned back to the pelvis. The ileum had some adhesions in the pelvis from her previous surgery. These were freed laparoscopically using the harmonic scalpel,and then a small laparotomy incision was made in the midline connecting our two midline laparoscopic ports. Ultimately, we had to extend the incision just below the umbilicus in order to free some additional adhesions in the pelvis, but we were able to exteriorize the bowel completely and elevate it. At this point two prominent lymph nodes in the right gastroepiploic region and the greater curvature of the stomach were identified. They were slightly firm. These were a little concerning for metastatic disease and the larger node was excised using harmonic scalpel and sent down for frozen section analysis. This returned negative for malignancy.
An Appropriate area of the terminal ileum was identified. The bowel was separated from its mesentery using Bovie cautery and then staple ligated with a GIA-55 with a blue load. Using a combination of harmonic scalpel, sharp dissection and GIA-55 vascular staple loads the mesentery of the right colon was divided. There were several enlarged nodes at the middle colic vessels. The mass was identified in the proximal transverse colon, several centimeters proximal to the middle colic vessels. But because of the adenopathy in the middle colic mesentery, we decided to take this vessel with our specimen as well. The root of the middle colic vessel as it came off the SMA was identified and separated. There was no adenopathy here. Using a vascular stapler these were staple ligated and then the rest of the transverse colon mesentery was incised. The distal transverse colon was identified. A window was created between the bowel and its mesentery and then using a GIA-75 with a blue load, the bowel was staple ligated in this location. The right colon and most of the transverse colon were then passed off the field as a specimen. The area was copiously irrigated and inspected for hemostasis which was complete. We then turned our attention to recreating bowel continuity.
The ileum and transverse colon were brought alongside each other and secured with 3-0 Vicryl suture. Small enterotomies were made in the antimesenteric portion of the bowel and then using a GIA-75, a stapled side-to-side functional end-to-end anastomosis was created. The resulting enterotomy was closed using a TL-60 stapler and then all staple lines were oversewn with 3-0 Vicryl imbricated as a running Lembert suture. The anastomosis was patent to palpation. It was examined and noted to be without obvious leaks, and then the mesentery was closed using a running 3-0 Vicryl stitch to close down the defect and prevent internal herniation. The abdomen was again irrigated. The bowel was returned to its normal anatomic position. Seprafilm was placed in the abdomen to try and minimize perioperative adhesion formation. Several sheets were placed in the pelvis and the rest were placed just below the fascia. Using looped #1 PDS the fascia was then reapproximated. The knot was buried. Subcutaneous tissue was irrigated.
The midline laparotomy skin was reapproximated using skin staples. The small laparoscopic port sites were closed with 4-0 Monocryl in subcuticular fashion. Sponge, needle and instrument counts were correct at the end of the case. Total fluids were 2200 mL. EBL was estimated at 150 mL. Urine output 200. The orogastric tube was removed. The Foley catheter was left in place at the conclusion of the case. The patient was awakened from anesthesia and transferred to recovery room in stable condition at the conclusion of the operation.
