Can someone please help me! My doc is going in to finish a prior colectomy. He's completing the colostomy and mucous fistula. Code 44144 includes the partial colectomy, not sure how this should be coded. Thanks in advance!:D
The patient was placed in the supine position and prepped and draped in the standard usual fashion. Next, the old wound VAC and material were removed and the bowel was exposed. Next, we turned out attention towards the right upper quadrant where the previous abdominal packs were left. As we were running the small bowel and got close to the right upper quadrant, we visualized abdominal packs. Some normal saline was applied to give us the ability to pull the packs and the packs were removed without difficulty. The tissue bed underneath was evaluated and found to be hemostatic. We evaluated the old duodenal injury which was repaired primarily and it was deemed to be in good shape. No further repair was deemed necessary. We also evaluated the porta hepatis. There was no bleeding or active leakage of bile, but bile staining was seen. Next, we took the greater omentum available and mobilized it near the previous injuries to provide added security in case something leaks. We pulled it near the old duodenal injury, as well as porta hepatis, and secured it in the vicinity with 3-0 interrupted Vicryl sutures. Next, the blind loop of the ascending colon was seen. We took the time to mobilize part of it to free it up enough in order to bring up an ostomy on the right side. After this was done, our attention was turned to the left blind loop of the transverse colon which was mobilized enough in order for it to be brought up on the opposite side for a mucous fistula. Care was taken to ensure hemostasis with electrocautery along the way. Next, we created the opening for the ostomy on the right side. With electrocautery, an approximately 2-cm diameter circle was incised with cutting electrocautery. Dissection was carried down to the fascia with coagulation electrocautery. Next, the fascia was entered and Kelly clamps were used to bluntly spread through the muscle fibers of the rectus abdominis and the rest of the abdominal wall muscles, penetrated through into the peritoneal side. Next, the opening was dilated by blunt dissection with fingers until enough of was freed in order to bring up an ostomy through it. Next, the ascending colon was pulled through the opening and secured in place with a Babcock. Next, the same process was undertaken on the left side of the abdomen where an ostomy opening was created and the transverse colon was brought through that hole and secured in place with a Babcock for the moment. Afterwards, we proceeded with J-tube placement. We ran the small bowel until we found the ligament of Treitz. Approximately 10-15 cm below it, we decided to make enterotomy. We passed a 16-French red rubber catheter which was secured in place with a pursestring suture. Next, we passed the red rubber catheter through the abdominal wall, on theupper left quadrant, underneath the ribcage. Three to four 3-0 Vicryl sutures were used to tach the jejunum to the abdominalwall, where the jejunostomy tube was pulled through. At this stage, we called in x-ray which brought in the C-arm and took pictures of the patient's chest and abdomen in order to ensure no more packs were left in the abdominal cavity. None were seen. Next, we turned our attention towards the possibility of closing the patient's abdomen. Judging by our ability to bring the fascial edges close together, it seemed feasible without too much tension. So, we proceeded with fascial closure with a 1.0 PDS suture. We started to close the incision from the top to the bottom, 3 total PDS sutures were used in the fascia. The fascia came together nicely without tension. Next the end colostomy and mucous fistula ostomy were matured, and sutured with 3-0 vicryl. Ostomy appliances were applied. Next, we decided to not staple the skin, but put on an incisional wound VAC instead.
The patient was placed in the supine position and prepped and draped in the standard usual fashion. Next, the old wound VAC and material were removed and the bowel was exposed. Next, we turned out attention towards the right upper quadrant where the previous abdominal packs were left. As we were running the small bowel and got close to the right upper quadrant, we visualized abdominal packs. Some normal saline was applied to give us the ability to pull the packs and the packs were removed without difficulty. The tissue bed underneath was evaluated and found to be hemostatic. We evaluated the old duodenal injury which was repaired primarily and it was deemed to be in good shape. No further repair was deemed necessary. We also evaluated the porta hepatis. There was no bleeding or active leakage of bile, but bile staining was seen. Next, we took the greater omentum available and mobilized it near the previous injuries to provide added security in case something leaks. We pulled it near the old duodenal injury, as well as porta hepatis, and secured it in the vicinity with 3-0 interrupted Vicryl sutures. Next, the blind loop of the ascending colon was seen. We took the time to mobilize part of it to free it up enough in order to bring up an ostomy on the right side. After this was done, our attention was turned to the left blind loop of the transverse colon which was mobilized enough in order for it to be brought up on the opposite side for a mucous fistula. Care was taken to ensure hemostasis with electrocautery along the way. Next, we created the opening for the ostomy on the right side. With electrocautery, an approximately 2-cm diameter circle was incised with cutting electrocautery. Dissection was carried down to the fascia with coagulation electrocautery. Next, the fascia was entered and Kelly clamps were used to bluntly spread through the muscle fibers of the rectus abdominis and the rest of the abdominal wall muscles, penetrated through into the peritoneal side. Next, the opening was dilated by blunt dissection with fingers until enough of was freed in order to bring up an ostomy through it. Next, the ascending colon was pulled through the opening and secured in place with a Babcock. Next, the same process was undertaken on the left side of the abdomen where an ostomy opening was created and the transverse colon was brought through that hole and secured in place with a Babcock for the moment. Afterwards, we proceeded with J-tube placement. We ran the small bowel until we found the ligament of Treitz. Approximately 10-15 cm below it, we decided to make enterotomy. We passed a 16-French red rubber catheter which was secured in place with a pursestring suture. Next, we passed the red rubber catheter through the abdominal wall, on theupper left quadrant, underneath the ribcage. Three to four 3-0 Vicryl sutures were used to tach the jejunum to the abdominalwall, where the jejunostomy tube was pulled through. At this stage, we called in x-ray which brought in the C-arm and took pictures of the patient's chest and abdomen in order to ensure no more packs were left in the abdominal cavity. None were seen. Next, we turned our attention towards the possibility of closing the patient's abdomen. Judging by our ability to bring the fascial edges close together, it seemed feasible without too much tension. So, we proceeded with fascial closure with a 1.0 PDS suture. We started to close the incision from the top to the bottom, 3 total PDS sutures were used in the fascia. The fascia came together nicely without tension. Next the end colostomy and mucous fistula ostomy were matured, and sutured with 3-0 vicryl. Ostomy appliances were applied. Next, we decided to not staple the skin, but put on an incisional wound VAC instead.