I have co surgeons performing on a patient. There are so many codes but almost all are bundled and I cannot figure out the best way to code this. Any help is appreciated:Exploratory laparotomy, pelvic mass resection with frozen section, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and aortic lymph node dissection, total omentectomy, tumor debulking by Dr. XXXX in with Dr. XXXXXX assisting
Colonoscopy, Ileocecectomy, Low Anterior Resection, Resection of mesenteric nodules/masses, mobilization of splenic flexure, ileostomy by Dr. XXXXX with Dr. XXXXX assisting
Procedure:
After a history and physical exam was reviewed and informed consent was confirmed. The patient was brought to the operating room and positioned in the supine position, and general anesthesia was achieved. SCDs were on prior to induction. Perioperative antibiotics were given and re-dosed as appropriate. The patient was then repositioned in the left lateral decubitus position. A colonoscopy was then performed. A digital rectal examination was performed first, and there was no palpable masses. The colonoscope was inserted into the anus and advanced to the cecum under direct visualization. The appendiceal orifice was clearly identified. There was evidence of extrinsic compression on the cecum but no intraluminal mass. The ileocecal valve was intubated, and the terminal ileum was visualized; that portion of the ileum appeared normal. The colonic mucosa was carefully examined as the colonoscope was withdrawn. The colonoic mucosa was normal appearing throughout. The colonoscope was then removed after suctioning as much air as possible.
The patient was the repositioned in the supine and then lithotomy position. Anesthesia placed an additional IV and arterila line. The patient was then prepped and draped in the usual sterile fashion. A foley catheter was placed.
A midline laparotomy incision was made, and the dissection was carried down to the fascia. The fascia was incised at the umbilicus and the peritoneal cavity was entered. The fascial incision was enlarged to the full length of the skin incision. The mass was easily identified taking up the pelvis and right lower quadrant. As we moved the omentum to expose the mass, we identified a large nodule in the omentum. The was removed right away and sent for frozen section. We inspected the rest of the omentum and saw no obvious nodules.
We turned our attention to the mass. The appendix, terminal ileum, and cecum were all draped over the mass and seemed almost "melted" into the mass. The entire right colon and hepatic flexure were mobilized to complete mobilization of the cranial aspect of the mass. A limited ileocecal resection was then performed, taking the mesentery just proximal to where the mass was part of the mesentery. This freed up the abdominal portion of the mass. We then placed the self-retaining retractor to expose the pelvis. During this portion of the dissection, pathology called to say that they could only confirm carcinoma in the specimen but not origin; their differential included neuroendocrine and serous carcinoma. The mass was adherent to the pelvic side wall/peritoneum on the right. The ureter was identified and separated from the tissue around the mass. The pelvic dissection was performed, and the mass was also contiguous with the right ovary. A right oopherectomy was performed. There was a little bit of remaining tissue tethering the mass to the patient; this was freed and the mass was sent to pathology to see if we could get a better determination of the type of cancer.
At this point, we performed the ileocolic anastomosis. A side to side, functional end to end, anastomosis was performed. We performed the right oopherectomy, as well. We also identified a mass in the cul-de-sac that was partially removed. Full excision would require a hysterectomy and low anterior resection. We were exploring the rest of the abdomen for evidence of disease. At this point, the pathology returned the diagnosis of serous ovarian cancer.
Since we had the upper abdomen exposed, we started with the complete omentectomy. To facilitate this dissection, a complete mobilization of the splenic flexure was performed. The entire left colon was also mobilized, taking care to protect the left ureter. There were two masses in the sigmoid mesentery; these were removed.
We then returned our dissection to the pelvis. A formal hysterectomy was performed. Once the uterus was out, the inferior mesenteric vessels were identified by sweeping under the mesentery at the sacral promontory just above the ureter. The inferior mesenteric vessels were divided just distal to the takeoff of the left colic artery. With the mobilization of the splenic flexure, we had enough mobility to reach even to create a colo-anal anastomosis.
The presacral plane was then identified, and sharp dissection was performed down to the pelvic floor posteriorly. The lateral attachments were then taken down. The most difficult part of the dissection was then anterior and anterolateral dissection of the peritoneal reflection because this is where the tumor was. Working from lateral to anterior, the entire peritoneal reflection was excised off the posterior wall of the vagina. Once this area was freed, we were able to get below tumor. A Contour stapler was used to divide the rectum at this location after clearing the mesorectum.
Prior to performing the anastomosis, a pelvic and para-aortic lymph node dissection was performed. Once this was complete, and hemostasis was obtained in the retroperitoneum. We performed the anastomosis. A pursestring suture was placed in the opening of the proximal colon. The anvil from the 28 EEA stapler was secured. The EEA stapler was then pass through the anus into the rectal stump. There was a sponge stick in the vagina so that we could retract it anteriorly and make sure that we did not have any vaginal wall in our staple line. The anvil was attached to the stapler, and the stapler was closed. The stapler was fired, and removed through the anus. The anvil was checked, and two complete anastomotic rings were identified. The anastomosis was tested by insufflation with air; no leak was identified. There was some proximal/distal separation between the vaginal cuff and the rectal anastomosis.
We then re-inspected the rest of the abdomen. No additional masses were identified. The abdomen was irrigated, and hemostasis was assured. The location for the ileostomy that was previously marked for the stoma was identified. A circular incision was made; the underlying tissue was incised until the fascia was identified. The fascia was incised vertically, the muscle was split, and the peritoneum was also incised vertically. Two fingers could be passed through the opening. A location on the distal ileum was chosen to bring up for the ileostomy. It was far enough proximal to all for an easy anastomosis. The loop was oriented with the defunctionalized limb superiorly. It was wrapped in seprafilm and then brought through the abdominal wall. The fascia was then closed with a running #1 PDS looped suture. The umbilicus was recreating with subcuticular Monocryl tacked to the fascia, and the remaining skin was closed with staples. The skin incision was covered with a blue towel while the ileostomy was matured.
The defunctionalized limb of the ileostomy was matured flush to the skin on the superior aspect. The functional limb was matured in a Brooke fashion. An ileostomy appliance was placed. Gloves were changed, and a sterile dressing was placed on the midline incision.
Estimated blood loss for the procedure was 500 cc. Needle, sponge, and instrument counts were reported correct.
The patient was taken out of the stirrups, placed on the table in the supine position, awakened in the operating room, and brought to the recovery room in stable condition.
