amanda19791
Networker
Does anyone have any suggestion for the situation below? Provider is using 44005 but the patient had a twisted bowel.
Procedure:
Midline laparotomy incision was made through the existing incision going through the umbilicus and the dissection was carried down through the skin and soft tissues entering the abdominal cavity. Minimal adhesions were initially encountered and the bowel was eviscerated. As I brought the distal bowel up I realized that the distal bowel was twisted underneath the mesenteric pedicle resulting in a partial obstruction. I was able to eviscerate the entire small bowel and discovered that because of the way the bowel had been the derotated during the initial operation, an internal hernia had occurred twisting the terminal ileum underneath the mesenteric pedicle as it was coursing down into the pelvis. The distended bowel was milked retrograde of enteric contents up into the stomach and the anesthetist remove the existing 10 French nasogastric tube, replacing this was a 14 French nasogastric tube to decompress the stomach. I initially attempted to untwist this down into the pelvis but I felt that this was compromising the blood supply to the distal bowel and ileoanal anastomosis. I therefore untwisted this retrograde all the way up to the ligament of Treitz and felt that if I took down the ligament of Treitz to completely derotate the entire bowel, this would result in releasing the twist on the mesenteric pedicle. I consulted my partner to come to the operating room and he examined the situation and agreed with this decision. The ligament of Treitz was taken down with blunt dissection and judicious electrocautery taking care to preserve the blood supply of the duodenum. Once the bowel was completely derotated I was able to determine that there was no kink in the bowel along its entire course and was assured that it would lie naturally within the abdominal cavity; there was no evidence of internal hernia. There was a small serosal tear that had occurred during the evisceration of the bowel and this was repaired longitudinally with interrupted 4-0 Vicryl suture in Lembert fashion. The bowel was quite pink throughout indicating restored blood supply. The bowel was returned to the abdominal cavity taking care to avoid kinking of the proximal small bowel and ensuring that the distal bowel went directly down to the pelvis without any tension on the mesenteric pedicle. The fascia was then closed with a running 4-0 PDS StrataFix suture. Marcaine was administered to the skin and soft tissues as an umbilical block. The wound was irrigated and then the dermis was approximated with running 4-0 Vicryl suture and the skin closed with running 4 Monocryl suture. Dermabond was applied as a sterile dressing. A bridle was used to secure the nasogastric tube which was connected to suction. The procedure was well tolerated, and there were no complications.
Procedure:
Midline laparotomy incision was made through the existing incision going through the umbilicus and the dissection was carried down through the skin and soft tissues entering the abdominal cavity. Minimal adhesions were initially encountered and the bowel was eviscerated. As I brought the distal bowel up I realized that the distal bowel was twisted underneath the mesenteric pedicle resulting in a partial obstruction. I was able to eviscerate the entire small bowel and discovered that because of the way the bowel had been the derotated during the initial operation, an internal hernia had occurred twisting the terminal ileum underneath the mesenteric pedicle as it was coursing down into the pelvis. The distended bowel was milked retrograde of enteric contents up into the stomach and the anesthetist remove the existing 10 French nasogastric tube, replacing this was a 14 French nasogastric tube to decompress the stomach. I initially attempted to untwist this down into the pelvis but I felt that this was compromising the blood supply to the distal bowel and ileoanal anastomosis. I therefore untwisted this retrograde all the way up to the ligament of Treitz and felt that if I took down the ligament of Treitz to completely derotate the entire bowel, this would result in releasing the twist on the mesenteric pedicle. I consulted my partner to come to the operating room and he examined the situation and agreed with this decision. The ligament of Treitz was taken down with blunt dissection and judicious electrocautery taking care to preserve the blood supply of the duodenum. Once the bowel was completely derotated I was able to determine that there was no kink in the bowel along its entire course and was assured that it would lie naturally within the abdominal cavity; there was no evidence of internal hernia. There was a small serosal tear that had occurred during the evisceration of the bowel and this was repaired longitudinally with interrupted 4-0 Vicryl suture in Lembert fashion. The bowel was quite pink throughout indicating restored blood supply. The bowel was returned to the abdominal cavity taking care to avoid kinking of the proximal small bowel and ensuring that the distal bowel went directly down to the pelvis without any tension on the mesenteric pedicle. The fascia was then closed with a running 4-0 PDS StrataFix suture. Marcaine was administered to the skin and soft tissues as an umbilical block. The wound was irrigated and then the dermis was approximated with running 4-0 Vicryl suture and the skin closed with running 4 Monocryl suture. Dermabond was applied as a sterile dressing. A bridle was used to secure the nasogastric tube which was connected to suction. The procedure was well tolerated, and there were no complications.