FGS2018
Guest
The provider completed a Hartmann Procedure two days prior to this procedure- I cannot find a decent code that fits this procedure- I am new to coding and I would appreciate any guidance.
Preoperative Diagnosis: Nausea, Vomiting, Abnormal CT scan, Rule out Ischemic Bowel
Postoperative Diagnosis: Most Likely Postop Ileus, Distended Rectal Stump.
Procedure: Exploratory Laparotomy with Decompression of Small Bowel and Rectal stump decompression.
Operative Report: After informed consent was obtained- we took the patient to the operating room, placed in the supine position. General Anesthesia administered. Prior Skin staples were removed. The abdomen was prepped and draped. The 0 PDS was then gently removed from the incision as well as the 3-0 nylon securing the prior JP drain, which was then removed. The abdomen was gently entered. We saw no evidence of purulent fluid. We then exteriorize the small bowel, which was pink and viable. It was mildly dilated down to the terminal ileum. The terminal ileum appeared to be decompressed, but there really was no mechanical obstruction noted. The small bowel was viable and unobstructed from the cecum to the ligament of Treitz. We then were able to milk the small bowel contents proximally into the stomach. We reposition the NG tube into the distal stomach. I did notice that the rectal stump appeared to be quite distended. We placed a new Jackson-pratt drain through the same stab incision and positioned it at the rectal stump. Copious amounts of warm irrigation were used to irrigate the abdomen. The greater mesentery was then placed over the top of the small bowel. The incision was closed with 0 Nurolon in uninterrupted figure of eight. Subcutaneous fat was then irrigated. The skin was closed with Wide skin Staples. The drain was secured with 3- nylon.
Preoperative Diagnosis: Nausea, Vomiting, Abnormal CT scan, Rule out Ischemic Bowel
Postoperative Diagnosis: Most Likely Postop Ileus, Distended Rectal Stump.
Procedure: Exploratory Laparotomy with Decompression of Small Bowel and Rectal stump decompression.
Operative Report: After informed consent was obtained- we took the patient to the operating room, placed in the supine position. General Anesthesia administered. Prior Skin staples were removed. The abdomen was prepped and draped. The 0 PDS was then gently removed from the incision as well as the 3-0 nylon securing the prior JP drain, which was then removed. The abdomen was gently entered. We saw no evidence of purulent fluid. We then exteriorize the small bowel, which was pink and viable. It was mildly dilated down to the terminal ileum. The terminal ileum appeared to be decompressed, but there really was no mechanical obstruction noted. The small bowel was viable and unobstructed from the cecum to the ligament of Treitz. We then were able to milk the small bowel contents proximally into the stomach. We reposition the NG tube into the distal stomach. I did notice that the rectal stump appeared to be quite distended. We placed a new Jackson-pratt drain through the same stab incision and positioned it at the rectal stump. Copious amounts of warm irrigation were used to irrigate the abdomen. The greater mesentery was then placed over the top of the small bowel. The incision was closed with 0 Nurolon in uninterrupted figure of eight. Subcutaneous fat was then irrigated. The skin was closed with Wide skin Staples. The drain was secured with 3- nylon.