RyanRaichCPC
Guest
Hello,
I am having trouble trying to properly code the following procedure and would appreciate any help.
POST OP DX: Obstructive Defectation secondary to internal rectal prolapse and large dissecting enterocele, and pelvic floor dysfunction
PROCEDURES PERFORMED: Robotic assisted ventral rectopexy with biodesign biologic graft, sacral colpoperineopexy
Indications for Px: PT is 53 y/o F who has had an insensate perineum and both urinary and defecatory dysfunction following a spine procedure. Pt requires self catheterization for emptying bladder. MR discography shows large enterocele pressing on rectum and internal rectal prolapse.
DESCRIPTION OF PX:
The patient was brought to the operating room where she was induced and intubated. Bilateral TAP blocks were placed. An expanded time-out was performed. She was prepped and draped in usual fashion. We began the operation with an OptiView access of the camera port in the supraumbilical region after anesthetizing the tissue with 0.5% Marcaine. She had relatively few adhesions in her abdomen; although, did have evidence of her previous Altemeier and hysterectomy with a fairly tight peritoneum given the Altemeier deepened the pelvis. We placed additional robotic ports and then an assistant port in the right upper quadrant for the AirSeal. The patient was placed into Trendelenburg and then small bowel was reflected up out of the large cul-de-sac. The robot was docked. I dissected down towards the peroneal body using the scissors. Her vagina was very foreshortened from previous laser treatment of HPV. I was able to digitally examine her and found that we were indeed to the peroneal body area. The Biodesign graft was then tapered and placed in the abdomen. It was secured with 2-0 PDS and then a series of 2-0 Vicryl along the anterior wall of the relocated rectal sigmoid and then sigmoid colon, and then up laterally after opening the peritoneum and exposing the anterior and lateral wall as much as possible. Given her tight peritoneum, I chose to make a peritoneal incision on her left side and I would use this to reperitonealize the pelvis excluding the graft at the end of the case. With at least eight sutures securing the graft to the rectum anteriorly, additional sutures were placed in the posterior vaginal wall and fixed to the graft anteriorly for the sacral colpoperineopexy part. I then cleaned the sacral promontory and placed two 2-0 Ethibond sutures that were then secured to the graft without tension. Additional sutures were placed to keep the graft splayed out and then the peritoneum was closed with running 3-0 PDS and leaving area for the sigmoid to easily go in and out of the extra-peritonealised distal large intestine area. The ports were removed under direct vision and the AirSeal port was closed with #0 Vicryl. The supraumbilical port was closed with 2-0 Vicryl. All port sites were irrigated. The sponge counts were reported as correct. Observation of the bowel revealed no evidence of any intestinal injury or retroperitoneal hematoma. Port sites were removed and there was no bleeding. The port sites were closed with 4-0 Monocryl and Dermabond.
Any takers??
I am having trouble trying to properly code the following procedure and would appreciate any help.
POST OP DX: Obstructive Defectation secondary to internal rectal prolapse and large dissecting enterocele, and pelvic floor dysfunction
PROCEDURES PERFORMED: Robotic assisted ventral rectopexy with biodesign biologic graft, sacral colpoperineopexy
Indications for Px: PT is 53 y/o F who has had an insensate perineum and both urinary and defecatory dysfunction following a spine procedure. Pt requires self catheterization for emptying bladder. MR discography shows large enterocele pressing on rectum and internal rectal prolapse.
DESCRIPTION OF PX:
The patient was brought to the operating room where she was induced and intubated. Bilateral TAP blocks were placed. An expanded time-out was performed. She was prepped and draped in usual fashion. We began the operation with an OptiView access of the camera port in the supraumbilical region after anesthetizing the tissue with 0.5% Marcaine. She had relatively few adhesions in her abdomen; although, did have evidence of her previous Altemeier and hysterectomy with a fairly tight peritoneum given the Altemeier deepened the pelvis. We placed additional robotic ports and then an assistant port in the right upper quadrant for the AirSeal. The patient was placed into Trendelenburg and then small bowel was reflected up out of the large cul-de-sac. The robot was docked. I dissected down towards the peroneal body using the scissors. Her vagina was very foreshortened from previous laser treatment of HPV. I was able to digitally examine her and found that we were indeed to the peroneal body area. The Biodesign graft was then tapered and placed in the abdomen. It was secured with 2-0 PDS and then a series of 2-0 Vicryl along the anterior wall of the relocated rectal sigmoid and then sigmoid colon, and then up laterally after opening the peritoneum and exposing the anterior and lateral wall as much as possible. Given her tight peritoneum, I chose to make a peritoneal incision on her left side and I would use this to reperitonealize the pelvis excluding the graft at the end of the case. With at least eight sutures securing the graft to the rectum anteriorly, additional sutures were placed in the posterior vaginal wall and fixed to the graft anteriorly for the sacral colpoperineopexy part. I then cleaned the sacral promontory and placed two 2-0 Ethibond sutures that were then secured to the graft without tension. Additional sutures were placed to keep the graft splayed out and then the peritoneum was closed with running 3-0 PDS and leaving area for the sigmoid to easily go in and out of the extra-peritonealised distal large intestine area. The ports were removed under direct vision and the AirSeal port was closed with #0 Vicryl. The supraumbilical port was closed with 2-0 Vicryl. All port sites were irrigated. The sponge counts were reported as correct. Observation of the bowel revealed no evidence of any intestinal injury or retroperitoneal hematoma. Port sites were removed and there was no bleeding. The port sites were closed with 4-0 Monocryl and Dermabond.
Any takers??