CCANTER
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i was trying to determine if this should be 44147 vs 44145. Any thoughts please?
A midline incision was made from the xiphoid to just above the pubic bone. This was carried down with electrocautery to the fascia which was elevated between 2 Kocher's and incised. The intra-abdominal cavity was directly visualized. The fascia was then opened to the length of the incision with care to protect the underlying bowel. The abdomen was explored. There was a very large mass in the left upper quadrant. There was no peritoneal studding, no obvious liver metastasis, and on palpation no other palpable disease in the proximal colon. There was some lymphadenopathy in the mesentery attached to the distal transverse and descending colon. No other obvious disease in the abdomen.
A Bookwalter was placed and the patient was placed slightly rotated to her right side down to allow the bowel to fall away. The bowel was then carefully retracted with malleable Bookwalter retractors. Lateral attachments of the sigmoid colon and descending colon were taken down to mobilize the colon from lateral to medial. The left ureter was identified and protected throughout the case. The mass in the descending colon was very large and there was omentum adhesed to it as well as adhesions to the lateral abdominal wall. A LigaSure device was used to divide the omentum to free up the uninvolved omentum from the mass. A combination of electrocautery and LigaSure were used to free up the mass from the lateral abdominal wall peritoneum. A segment of the peritoneum was removed with the specimen en bloc as well as with the overlying omentum and, Gerota's fascia.
At the mid transverse colon, the greater omentum was retracted superiorly and the avascular plane between the omentum and the colon was entered with electrocautery. The omentum was divided free of the colon with a combination of LigaSure and electrocautery. The lesser sac was entered. There was no disease or metastatic involvement identified there. This was continued laterally to free up the entire transverse colon from its superior attachments including the splenocolic ligament and the pancreaticocolic ligament. The distal transverse colon was dissected from the stomach by freeing the greater omentum. The mass was still firmly attached to the deep structures of the retroperitoneum. Attention was turned to the sigmoid and rectum. The distal point of transection was made at the confluence of the tinea at the rectosigmoid junction with a GIA stapler. The mesentery was divided with a LigaSure device and the superior rectal artery was ligated with HemoLock polymer clips.
The proximal point of transection was made in the mid-transverse colon preserving the middle colic artery. The transfer colon was divided with a 75 mm GIA stapler. The mesentery was divided with the LigaSure device continuing laterally towards the mass. The mass was densely adhesed to Gerota's fascia. The anterior portion of Gerota's fascia was divided and sent en bloc with the specimen. Finally, the IMA was divided also with the LigaSure device and the specimen was removed from the abdominal cavity. A silk stitch was placed to mark the distal colon. The specimen was passed off to be sent to pathology.
The abdomen was irrigated copiously with sterile water. The transverse colon was able to reach the rectal stump without tension. The anus was gently dilated with 2 fingers. The rectum was sized to 29 mm. The 29 mm EEA stapler was selected.
The transverse colon staple line was removed with scissors and the anvil was sewn into the bowel with a 2-0 Prolene pursestring. The EEA was introduced through the anus to the staple line and the anastomosis was made anterior to the staple line. The anastomosis was created without tension. The donuts appeared intact.
The colonoscope was used to perform a bubble test and the anastomosis was visualized intact. There were no bubbles. The abdomen was copiously irrigated with sterile saline. A 15 French round drain was placed through a separate stab incision in the left abdomen running down into the pelvis.
The cecume and small bowel were unpacked and allowed to return to normal position and without any twisting. The fascia was closed with a running number 0 PDS. Scarpa's fasscia was reapproximated with a running 3-0 vicryl. The dermis was reapproximated with interrupted 3-0 Vicryl sutures. Skin was closed with skin staples. A sterile dressing consisting of Xeroform and gauze was taped in place. .
Kelly Casey, MD
Dragon Medical dictation program may have been used in preparation of this note. All attempts to ensure the accuracy of the note were made, at times there can be misspelling or incorrect translation of the recorded voice. Please use context of the note to interpret the meaning.
A midline incision was made from the xiphoid to just above the pubic bone. This was carried down with electrocautery to the fascia which was elevated between 2 Kocher's and incised. The intra-abdominal cavity was directly visualized. The fascia was then opened to the length of the incision with care to protect the underlying bowel. The abdomen was explored. There was a very large mass in the left upper quadrant. There was no peritoneal studding, no obvious liver metastasis, and on palpation no other palpable disease in the proximal colon. There was some lymphadenopathy in the mesentery attached to the distal transverse and descending colon. No other obvious disease in the abdomen.
A Bookwalter was placed and the patient was placed slightly rotated to her right side down to allow the bowel to fall away. The bowel was then carefully retracted with malleable Bookwalter retractors. Lateral attachments of the sigmoid colon and descending colon were taken down to mobilize the colon from lateral to medial. The left ureter was identified and protected throughout the case. The mass in the descending colon was very large and there was omentum adhesed to it as well as adhesions to the lateral abdominal wall. A LigaSure device was used to divide the omentum to free up the uninvolved omentum from the mass. A combination of electrocautery and LigaSure were used to free up the mass from the lateral abdominal wall peritoneum. A segment of the peritoneum was removed with the specimen en bloc as well as with the overlying omentum and, Gerota's fascia.
At the mid transverse colon, the greater omentum was retracted superiorly and the avascular plane between the omentum and the colon was entered with electrocautery. The omentum was divided free of the colon with a combination of LigaSure and electrocautery. The lesser sac was entered. There was no disease or metastatic involvement identified there. This was continued laterally to free up the entire transverse colon from its superior attachments including the splenocolic ligament and the pancreaticocolic ligament. The distal transverse colon was dissected from the stomach by freeing the greater omentum. The mass was still firmly attached to the deep structures of the retroperitoneum. Attention was turned to the sigmoid and rectum. The distal point of transection was made at the confluence of the tinea at the rectosigmoid junction with a GIA stapler. The mesentery was divided with a LigaSure device and the superior rectal artery was ligated with HemoLock polymer clips.
The proximal point of transection was made in the mid-transverse colon preserving the middle colic artery. The transfer colon was divided with a 75 mm GIA stapler. The mesentery was divided with the LigaSure device continuing laterally towards the mass. The mass was densely adhesed to Gerota's fascia. The anterior portion of Gerota's fascia was divided and sent en bloc with the specimen. Finally, the IMA was divided also with the LigaSure device and the specimen was removed from the abdominal cavity. A silk stitch was placed to mark the distal colon. The specimen was passed off to be sent to pathology.
The abdomen was irrigated copiously with sterile water. The transverse colon was able to reach the rectal stump without tension. The anus was gently dilated with 2 fingers. The rectum was sized to 29 mm. The 29 mm EEA stapler was selected.
The transverse colon staple line was removed with scissors and the anvil was sewn into the bowel with a 2-0 Prolene pursestring. The EEA was introduced through the anus to the staple line and the anastomosis was made anterior to the staple line. The anastomosis was created without tension. The donuts appeared intact.
The colonoscope was used to perform a bubble test and the anastomosis was visualized intact. There were no bubbles. The abdomen was copiously irrigated with sterile saline. A 15 French round drain was placed through a separate stab incision in the left abdomen running down into the pelvis.
The cecume and small bowel were unpacked and allowed to return to normal position and without any twisting. The fascia was closed with a running number 0 PDS. Scarpa's fasscia was reapproximated with a running 3-0 vicryl. The dermis was reapproximated with interrupted 3-0 Vicryl sutures. Skin was closed with skin staples. A sterile dressing consisting of Xeroform and gauze was taped in place. .
Kelly Casey, MD
Dragon Medical dictation program may have been used in preparation of this note. All attempts to ensure the accuracy of the note were made, at times there can be misspelling or incorrect translation of the recorded voice. Please use context of the note to interpret the meaning.