NancyZ76
Contributor
Hello,
Could anyone help with coding this. These were done on the same day. 44144-58/44160???
Procedure 1
PREOPERATIVE DIAGNOSIS:
Obstructing sigmoid colon cancer with secondary abdominal compartment syndrome.
*
POSTOPERATIVE DIAGNOSIS:
Obstructing sigmoid colon cancer with secondary abdominal compartment syndrome.
*
PROCEDURE:
Double-barrel transverse colostomy.
*
*
HISTORY:
This is a 65-year-old male admitted early this morning with a bowel obstruction secondary to an obstruction from a distal sigmoid rectal cancer. The patient started to develop respiratory distress this morning and was admitted to the ICU. I was asked to consult. Examination revealed markedly distended abdomen. Review of the CAT scan showed marked distention of both small and large bowel. It was decided to proceed with surgery. Because the patient was not in stable condition, we decided to do the minimal amount of surgery necessary, which would be to construct a double-barrel transverse colostomy.
*
DESCRIPTION OF PROCEDURE:
With the patient under satisfactory general anesthesia in a supine position on the operating room table, the patient's abdomen was prepped with ChloraPrep and draped in the usual manner. A small incision was made in the upper midline. Incision was carried down through subcutaneous tissue exposing the fascia. The fascia was divided and the peritoneum was divided exposing the colon. The colon was massively distended. It was able to be gently milked out of the incision. A bridge was placed behind it through the mesentery to keep it elevated. The colon was then opened with a large amount of air being expelled. The colostomy was matured with multiple interrupted sutures of 0 chromic. The bowel was slightly dusky, but it did appear to be viable. A bag was applied over it. A consideration was made of doing the exploratory laparotomy, but it was decided because of the patient's condition that we would try to decompress him for the next few hours, then I would do serial observations over the afternoon and evening to make sure that there was no decompensation of his condition indicating possible ischemic bowel. The patient tolerated the procedure well and was taken back to the ICU in stable condition.
*
ESTIMATED BLOOD LOSS:
Less than 5 mL.
*
COMPLICATIONS:
None.
*
FINDINGS:
Massively dilated transverse colon.
Procedure 2
POSTOPERATIVE DIAGNOSIS:
Extensive ischemic small and large bowel.
*
PROCEDURE:
Exploratory laparotomy, resection of ileum and ascending colon, decompression of colon with creation of ileostomy, mucous fistula of the remaining ascending colon, and loop colostomy of sigmoid colon.
*
*
HISTORY:
This is a 65-year-old male initially admitted the night before to the medical service with a bowel obstruction, colon indicated a probable obstructing distal sigmoid colon lesion with possible liver metastases. It showed extensive large and small bowel distention. Early the next morning, the patient was transferred to the ICU after deterioration and placed on pressors. I was asked to see the patient at that point. He was extremely unstable. He was taken to the operating room where I performed a loop stoma to decompress the abdomen because the abdomen was very tense with a probable abdominal compartment syndrome. This patient was taken back to the ICU. The abdomen was much softer and bladder pressures indicated improvement in the abdominal pressure with some partial decompression through the stoma. Initially, the patient seemed to have some stabilization. I saw the patient frequently that afternoon and it was discussed multiple times with the intensivist. Initially, we thought the patient was doing slightly better, but then at approximately 5:00 to 6:00 in the evening, there was a decrease in the blood pressure and we immediately decided to return to the OR knowing that this would probably be a heroic procedure since the patient was unstable with both short term poor prognosis from acute abdominal crisis from possible ischemic bowel in addition to his long-term poor prognosis from probable metastatic colon cancer.
*
DESCRIPTION OF PROCEDURE:
With the patient in the OR already intubated, a long midline incision was made. Immediately, extensive small bowel ischemia was encountered. Approximately half the small bowel was dead. There was not any significant spillage though. The bowel was divided proximal to the ischemia at approximately the level of the junction between the jejunum and ileum and distally just proximal to the ileocecal valve. This involved segment was resected by using the LigaSure machine to transect the involved mesentery. After this was removed, the rest of the bowel was inspected. It was intact; however, there was extensive distention of both small and large bowel. Sigmoid colon was quite distended. A pursestring was placed around an area in the sigmoid that was weakened from some serosal tears from the distention. A hole was made in the bowel in the center of the pursestring, and extensive stool was able to be milked out of the sigmoid colon from both the afferent and efferent limbs. The bowel was decompressed as much as possible. This loop was then brought out through a hole in the left lower quadrant as a double barrel loop sigmoid colostomy. The terminal ileum and ascending colon was then inspected. It seemed to be slightly dusky and it was decided to remove this as well. It was mobilized and transected at approximately the mid ascending colon where it was viable. The bowel was unable to be decompressed from this direction as well. It was mostly air. This was brought out as a mucous fistula in the right upper quadrant, so this segment of colon was decompressed both proximally and distally. The remaining small bowel, which is either proximal ileum or distal jejunum, was then brought out through the right lower quadrant as an end ileostomy. The abdomen was then irrigated and it appeared all of the remaining bowel was grossly viable. Probable liver metastases were palpated in the liver. The fascia was then closed with a running suture of double stranded #1 PDS. The skin was left open by packing it with saline-soaked gauze and sterile dressings were applied. The small bowel ileostomy was matured with multiple interrupted sutures of 0 chromic. The proximal colon mucous fistula was likewise matured with 0 chromic sutures. A bridge was placed underneath the colon in the left lower quadrant for the loop colostomy. Sterile dressings were applied. Patient survived the operation and was taken back to the intensive care unit on a ventilator. He remained on pressors as before the surgery.
*
FINDINGS:
Extensive small and large bowel ischemia. The patient in very unstable condition.
*
Could anyone help with coding this. These were done on the same day. 44144-58/44160???
Procedure 1
PREOPERATIVE DIAGNOSIS:
Obstructing sigmoid colon cancer with secondary abdominal compartment syndrome.
*
POSTOPERATIVE DIAGNOSIS:
Obstructing sigmoid colon cancer with secondary abdominal compartment syndrome.
*
PROCEDURE:
Double-barrel transverse colostomy.
*
*
HISTORY:
This is a 65-year-old male admitted early this morning with a bowel obstruction secondary to an obstruction from a distal sigmoid rectal cancer. The patient started to develop respiratory distress this morning and was admitted to the ICU. I was asked to consult. Examination revealed markedly distended abdomen. Review of the CAT scan showed marked distention of both small and large bowel. It was decided to proceed with surgery. Because the patient was not in stable condition, we decided to do the minimal amount of surgery necessary, which would be to construct a double-barrel transverse colostomy.
*
DESCRIPTION OF PROCEDURE:
With the patient under satisfactory general anesthesia in a supine position on the operating room table, the patient's abdomen was prepped with ChloraPrep and draped in the usual manner. A small incision was made in the upper midline. Incision was carried down through subcutaneous tissue exposing the fascia. The fascia was divided and the peritoneum was divided exposing the colon. The colon was massively distended. It was able to be gently milked out of the incision. A bridge was placed behind it through the mesentery to keep it elevated. The colon was then opened with a large amount of air being expelled. The colostomy was matured with multiple interrupted sutures of 0 chromic. The bowel was slightly dusky, but it did appear to be viable. A bag was applied over it. A consideration was made of doing the exploratory laparotomy, but it was decided because of the patient's condition that we would try to decompress him for the next few hours, then I would do serial observations over the afternoon and evening to make sure that there was no decompensation of his condition indicating possible ischemic bowel. The patient tolerated the procedure well and was taken back to the ICU in stable condition.
*
ESTIMATED BLOOD LOSS:
Less than 5 mL.
*
COMPLICATIONS:
None.
*
FINDINGS:
Massively dilated transverse colon.
Procedure 2
POSTOPERATIVE DIAGNOSIS:
Extensive ischemic small and large bowel.
*
PROCEDURE:
Exploratory laparotomy, resection of ileum and ascending colon, decompression of colon with creation of ileostomy, mucous fistula of the remaining ascending colon, and loop colostomy of sigmoid colon.
*
*
HISTORY:
This is a 65-year-old male initially admitted the night before to the medical service with a bowel obstruction, colon indicated a probable obstructing distal sigmoid colon lesion with possible liver metastases. It showed extensive large and small bowel distention. Early the next morning, the patient was transferred to the ICU after deterioration and placed on pressors. I was asked to see the patient at that point. He was extremely unstable. He was taken to the operating room where I performed a loop stoma to decompress the abdomen because the abdomen was very tense with a probable abdominal compartment syndrome. This patient was taken back to the ICU. The abdomen was much softer and bladder pressures indicated improvement in the abdominal pressure with some partial decompression through the stoma. Initially, the patient seemed to have some stabilization. I saw the patient frequently that afternoon and it was discussed multiple times with the intensivist. Initially, we thought the patient was doing slightly better, but then at approximately 5:00 to 6:00 in the evening, there was a decrease in the blood pressure and we immediately decided to return to the OR knowing that this would probably be a heroic procedure since the patient was unstable with both short term poor prognosis from acute abdominal crisis from possible ischemic bowel in addition to his long-term poor prognosis from probable metastatic colon cancer.
*
DESCRIPTION OF PROCEDURE:
With the patient in the OR already intubated, a long midline incision was made. Immediately, extensive small bowel ischemia was encountered. Approximately half the small bowel was dead. There was not any significant spillage though. The bowel was divided proximal to the ischemia at approximately the level of the junction between the jejunum and ileum and distally just proximal to the ileocecal valve. This involved segment was resected by using the LigaSure machine to transect the involved mesentery. After this was removed, the rest of the bowel was inspected. It was intact; however, there was extensive distention of both small and large bowel. Sigmoid colon was quite distended. A pursestring was placed around an area in the sigmoid that was weakened from some serosal tears from the distention. A hole was made in the bowel in the center of the pursestring, and extensive stool was able to be milked out of the sigmoid colon from both the afferent and efferent limbs. The bowel was decompressed as much as possible. This loop was then brought out through a hole in the left lower quadrant as a double barrel loop sigmoid colostomy. The terminal ileum and ascending colon was then inspected. It seemed to be slightly dusky and it was decided to remove this as well. It was mobilized and transected at approximately the mid ascending colon where it was viable. The bowel was unable to be decompressed from this direction as well. It was mostly air. This was brought out as a mucous fistula in the right upper quadrant, so this segment of colon was decompressed both proximally and distally. The remaining small bowel, which is either proximal ileum or distal jejunum, was then brought out through the right lower quadrant as an end ileostomy. The abdomen was then irrigated and it appeared all of the remaining bowel was grossly viable. Probable liver metastases were palpated in the liver. The fascia was then closed with a running suture of double stranded #1 PDS. The skin was left open by packing it with saline-soaked gauze and sterile dressings were applied. The small bowel ileostomy was matured with multiple interrupted sutures of 0 chromic. The proximal colon mucous fistula was likewise matured with 0 chromic sutures. A bridge was placed underneath the colon in the left lower quadrant for the loop colostomy. Sterile dressings were applied. Patient survived the operation and was taken back to the intensive care unit on a ventilator. He remained on pressors as before the surgery.
*
FINDINGS:
Extensive small and large bowel ischemia. The patient in very unstable condition.
*
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