sara0014
Contributor
Needing assistants on making sure I am picking up all the right CPT codes. I am fairly new on general surgery coding. Still looking for more input on this.
PREOPERATIVE DIAGNOSIS: Cecal volvulus.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Exploratory laparotomy, right hemicolectomy.
ANESTHESIA: General endotracheal.
She presented with severe abdominal pain which began last night. She had some vague, very intermittent symptomatology over the past year. CAT scan done today shows a cecal volvulus. She has a mildly tender abdomen. She obviously has a lot more pain than is reflected by her physical exam.
FINDINGS: Cecal volvulus, classic, all presented in the left side of the abdomen, exactly as characterized by radiology. A few minimal adhesions from her old appendectomy. The cecum is not necrotic, but I resected it. Her transverse colon is nicely decompressed.
PROCEDURE: General endotracheal anesthesia, Chloraprep. SCDs and Foley. Mefoxin 2 gm were given before we took her to the operating room. A low midline incision made after appropriate draping. We entered her abdomen easily. Dilated distal small bowel, proximal small bowel was not very dilated. Stomach is quite dilated. The cecum is huge and lodge in the left lower quadrant. I extended her incision a little bit and then exteriorized everything and de-rotated the volvulus, which was very interesting to see in a lady with this body habitus. All of her anatomy is very easily seen. We reflected the whole right colon and the hepatic flexure, divided the transverse colon with a GIA, the ileum with a GIA, then did a side to side ileotransverse colostomy with GIA staplers. A TA 60 was used to occlude the two open portions of the bowel used to insert the GIA. Mesenteric defects were closed with interrupted 3-0 Vicryl. Counts were correct twice. There was absolutely no bleeding. I rechecked the mesenteric defect. It is gone, and the transverse colon and distal most ileum was placed in the right gutter in an anatomic position. All small bowel removed were replaced into the abdomen gently and easily, with care taken to make sure her mesentery is lined properly.
Final counts were correct. We closed her abdomen with running #1 Vicryl from above and below and stapled her skin.
EBL: 50 mL or less.
COMPLICATIONS: None.
DRAINS: None.
PREOPERATIVE DIAGNOSIS: Cecal volvulus.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Exploratory laparotomy, right hemicolectomy.
ANESTHESIA: General endotracheal.
She presented with severe abdominal pain which began last night. She had some vague, very intermittent symptomatology over the past year. CAT scan done today shows a cecal volvulus. She has a mildly tender abdomen. She obviously has a lot more pain than is reflected by her physical exam.
FINDINGS: Cecal volvulus, classic, all presented in the left side of the abdomen, exactly as characterized by radiology. A few minimal adhesions from her old appendectomy. The cecum is not necrotic, but I resected it. Her transverse colon is nicely decompressed.
PROCEDURE: General endotracheal anesthesia, Chloraprep. SCDs and Foley. Mefoxin 2 gm were given before we took her to the operating room. A low midline incision made after appropriate draping. We entered her abdomen easily. Dilated distal small bowel, proximal small bowel was not very dilated. Stomach is quite dilated. The cecum is huge and lodge in the left lower quadrant. I extended her incision a little bit and then exteriorized everything and de-rotated the volvulus, which was very interesting to see in a lady with this body habitus. All of her anatomy is very easily seen. We reflected the whole right colon and the hepatic flexure, divided the transverse colon with a GIA, the ileum with a GIA, then did a side to side ileotransverse colostomy with GIA staplers. A TA 60 was used to occlude the two open portions of the bowel used to insert the GIA. Mesenteric defects were closed with interrupted 3-0 Vicryl. Counts were correct twice. There was absolutely no bleeding. I rechecked the mesenteric defect. It is gone, and the transverse colon and distal most ileum was placed in the right gutter in an anatomic position. All small bowel removed were replaced into the abdomen gently and easily, with care taken to make sure her mesentery is lined properly.
Final counts were correct. We closed her abdomen with running #1 Vicryl from above and below and stapled her skin.
EBL: 50 mL or less.
COMPLICATIONS: None.
DRAINS: None.
