frankal
Contributor
Please Help!
I am looking for help in coding for a procedure that was performed.
Part of Op Note:
Our robotic arms were then brought up to the patient's bedside and secured to the ports. The
robotic instruments and camera were then inserted. I then moved over to the robotic console
and took control of the instruments. A careful inspection of the abdominal cavity was
performed. We identified that there was sigmoid colon going up into the left inguinal
hernia. There was also some omentum and epiploic appendages from the colon going up into
this area. Careful retraction was performed on the colon and the omentum to reduce the
contents of the left inguinal hernia. We reduced much of the omentum and some of the
epiploic appendages that were contained within the hernia; however, the sigmoid colon was
still difficult to completely reduce. We then began by dissecting our preperitoneal plane to
see if we could dissect the hernia sac free so that the entire the hernia sac and
incarcerated contents would completely reduced. We created a preperitoneal pocket by using
scissors with electrocautery. We carefully dissected within this preperitoneal plane down
towards the pubic arch and identify the pubic arch and Cooper ligament. We then also
dissected laterally far enough to allow for mesh placement. As we for further dissected down
to the hernia sac, we were still encountering difficulties with dissecting the hernia sac
free. We then exchanged the scissors for another Cadiere forceps. A Cadiere grasper was
used to help attempt to reduce the sigmoid colon. We carefully bluntly began taking down
some of the adhesions around the sigmoid colon to help us reduce the sigmoid colon from
within the deep inguinal ring. After carefully attempting dissection and adhesiolysis for
approximately 2 hours, we then decided to abort the laparoscopic procedure and had to convert
to an open exploratory laparotomy so that we could completely reduce the colon. The robotic
instruments were removed and the robotic arms were disengaged from the ports and removed away
from the patient's bedside. The ports were then removed and the pneumoperitoneum was
released. A vertical midline incision was made from the pubic bone up to the umbilicus using
a 10 blade scalpel. Electrocautery was used for hemostasis and for dissection down through
Scarpa fascia. The linea alba was then incised using electrocautery. We then identified the
peritoneum and grasped this using 2 hemostats and lifted it anteriorly. The peritoneum was
then entered using electrocautery. We then carefully explored the abdomen and placed an
Alexis wound protector within the midline incision. We then carefully traced the descending
colon up to the sigmoid colon where it was incarcerated within the inguinal hernia. We
carefully bluntly dissected the sigmoid colon free from the inguinal canal. This still took
another 2 hours of open adhesiolysis to the point where we were able to completely free up
the sigmoid colon. As we were doing this, we encountered more bleeding due to retraction on
the mesocolon. We also noted some serosal tears along the colon as we were continuing to
reduce it. Some of these tears appeared to create a very thin wall in the sigmoid colon.
Once we were able to finally completely reduce the colon from within the inguinal canal, this
colon did not appear healthy and viable. Therefore, it was going to require resection. The
distal sigmoid colon appeared healthy and viable as well as the proximal descending colon.
We took down some of the lateral attachments to the descending colon so that we had adequate
mobilization to create a tension-free anastomosis. A GIA 75 mm blue load stapler was then
advanced across the sigmoid colon distal to our damaged area of colon and this was clamped
and fired to transect the colon at this point. A blue reload was then clamped across the
descending colon and fired. The mesocolon attachments were then taken down using LigaSure
electrocautery. The specimen was removed and sent to the lab for pathology.
Would I code for the aborted lap ing hernia repair? Can I code for the ahesiolysis since it was well over 50 % of operating time?
Thanks!
I am looking for help in coding for a procedure that was performed.
Part of Op Note:
Our robotic arms were then brought up to the patient's bedside and secured to the ports. The
robotic instruments and camera were then inserted. I then moved over to the robotic console
and took control of the instruments. A careful inspection of the abdominal cavity was
performed. We identified that there was sigmoid colon going up into the left inguinal
hernia. There was also some omentum and epiploic appendages from the colon going up into
this area. Careful retraction was performed on the colon and the omentum to reduce the
contents of the left inguinal hernia. We reduced much of the omentum and some of the
epiploic appendages that were contained within the hernia; however, the sigmoid colon was
still difficult to completely reduce. We then began by dissecting our preperitoneal plane to
see if we could dissect the hernia sac free so that the entire the hernia sac and
incarcerated contents would completely reduced. We created a preperitoneal pocket by using
scissors with electrocautery. We carefully dissected within this preperitoneal plane down
towards the pubic arch and identify the pubic arch and Cooper ligament. We then also
dissected laterally far enough to allow for mesh placement. As we for further dissected down
to the hernia sac, we were still encountering difficulties with dissecting the hernia sac
free. We then exchanged the scissors for another Cadiere forceps. A Cadiere grasper was
used to help attempt to reduce the sigmoid colon. We carefully bluntly began taking down
some of the adhesions around the sigmoid colon to help us reduce the sigmoid colon from
within the deep inguinal ring. After carefully attempting dissection and adhesiolysis for
approximately 2 hours, we then decided to abort the laparoscopic procedure and had to convert
to an open exploratory laparotomy so that we could completely reduce the colon. The robotic
instruments were removed and the robotic arms were disengaged from the ports and removed away
from the patient's bedside. The ports were then removed and the pneumoperitoneum was
released. A vertical midline incision was made from the pubic bone up to the umbilicus using
a 10 blade scalpel. Electrocautery was used for hemostasis and for dissection down through
Scarpa fascia. The linea alba was then incised using electrocautery. We then identified the
peritoneum and grasped this using 2 hemostats and lifted it anteriorly. The peritoneum was
then entered using electrocautery. We then carefully explored the abdomen and placed an
Alexis wound protector within the midline incision. We then carefully traced the descending
colon up to the sigmoid colon where it was incarcerated within the inguinal hernia. We
carefully bluntly dissected the sigmoid colon free from the inguinal canal. This still took
another 2 hours of open adhesiolysis to the point where we were able to completely free up
the sigmoid colon. As we were doing this, we encountered more bleeding due to retraction on
the mesocolon. We also noted some serosal tears along the colon as we were continuing to
reduce it. Some of these tears appeared to create a very thin wall in the sigmoid colon.
Once we were able to finally completely reduce the colon from within the inguinal canal, this
colon did not appear healthy and viable. Therefore, it was going to require resection. The
distal sigmoid colon appeared healthy and viable as well as the proximal descending colon.
We took down some of the lateral attachments to the descending colon so that we had adequate
mobilization to create a tension-free anastomosis. A GIA 75 mm blue load stapler was then
advanced across the sigmoid colon distal to our damaged area of colon and this was clamped
and fired to transect the colon at this point. A blue reload was then clamped across the
descending colon and fired. The mesocolon attachments were then taken down using LigaSure
electrocautery. The specimen was removed and sent to the lab for pathology.
Would I code for the aborted lap ing hernia repair? Can I code for the ahesiolysis since it was well over 50 % of operating time?
Thanks!