ATMOCH88
New
Procedure: 1. Ileocecectomy 2. Sigmoid colon resection with primary anastomosis 3.creation of end ileostomy. 4 drainage of mesenteric and pelvic abscess
Findings: Crohn's terminal ileitis with ileal sigmoid fistula. Mesenteric abscess extending onto the dome of the bladder. 20 cm of terminal ileum resected.
Specimens: terminal ileum and cecum, sigmoid colon
Procedure:
After appropriate consent including risks, benefits and alternatives were discussed with the patient, the patient was brought to the OR, and placed in the supine position. Anesthesia was administered.
A midline laparotomy incision was made and the abdomen explored. Palpation and inspection showed thickened inflamed terminal ileum with fistulous connection to the mid sigmoid colon. There was an abscess in the mesentery of the terminal ileum that was adherent to the dome of the bladder, the abscess cavity was broken and drained by manual dissection. There remainder of the small bowel and colon were normal.
The cecum was mobilized by incising the periotneum inferiorly and extending this superiorly with a combination of blunt and careful electrocautery dissection.
We were able to finger fracture the terminal ileum of the dome of the bladder. There was no cystotomy. We then elevated the terminal ileum and saw the sigmoid colon had a fistulous connection. We then identified our proximal and distal margins of resection of the cecum, terminal ileum and sigmoid colon. The mesentery to the cecum was taken with the ligasure device. The cecum as divided using a GIA 80 stapler. Identifying sutures of 2-0 prolene were placed.
The mesentery to the terminal ileum was divided with a combination of ligasure and clamp and stick tie technique. The mesentery to the sigmoid colon proximally and distally was taken with the ligasure. The terminal ileum was divided with a GIA 80 stapler. The proximal sigmoid was divided with the purse string 65 mm device. The distal sigmoid was divided after a Kocher clamp was placed. The anvil of the EEA 29 mm stapler was placed in the proximal sigmoid colon. The EEA stapler was placed in the distal sigmoid colon and the spike was deployed in the antimesenteric side. The stapler was mated without twisting or tension. The enterotomy was then closed with a TA 60 stapler. The abdomen was irrigated with 4 liters of saline to clean out the residual abscess cavity.
An ileostomy aperture was created by making a circular incision in a previously marked stoma location in the right lower quadrant. The anterior fascia was opened longitudinally. The rectus muscle was split and the posterior fascia opened longitudinally to allow two fingers. The terminal ileum was delivered without twisting or tension.
The fascia was closed with running #1 PDS. Interrupted 0 vicryl stitches were placed as internal retention sutures.
The incision was irrigated and the skin closed with staples and covered.
The ileum was opened in matured in brooke fashion taking full thickness bites of ileum followed by a serosal bite and then a dermal bite circumferentially.
Stoma appliance was then applied.
Please help me with coding this report. I dont believe that the Dr. is correct in his coding.
Thanks!
Findings: Crohn's terminal ileitis with ileal sigmoid fistula. Mesenteric abscess extending onto the dome of the bladder. 20 cm of terminal ileum resected.
Specimens: terminal ileum and cecum, sigmoid colon
Procedure:
After appropriate consent including risks, benefits and alternatives were discussed with the patient, the patient was brought to the OR, and placed in the supine position. Anesthesia was administered.
A midline laparotomy incision was made and the abdomen explored. Palpation and inspection showed thickened inflamed terminal ileum with fistulous connection to the mid sigmoid colon. There was an abscess in the mesentery of the terminal ileum that was adherent to the dome of the bladder, the abscess cavity was broken and drained by manual dissection. There remainder of the small bowel and colon were normal.
The cecum was mobilized by incising the periotneum inferiorly and extending this superiorly with a combination of blunt and careful electrocautery dissection.
We were able to finger fracture the terminal ileum of the dome of the bladder. There was no cystotomy. We then elevated the terminal ileum and saw the sigmoid colon had a fistulous connection. We then identified our proximal and distal margins of resection of the cecum, terminal ileum and sigmoid colon. The mesentery to the cecum was taken with the ligasure device. The cecum as divided using a GIA 80 stapler. Identifying sutures of 2-0 prolene were placed.
The mesentery to the terminal ileum was divided with a combination of ligasure and clamp and stick tie technique. The mesentery to the sigmoid colon proximally and distally was taken with the ligasure. The terminal ileum was divided with a GIA 80 stapler. The proximal sigmoid was divided with the purse string 65 mm device. The distal sigmoid was divided after a Kocher clamp was placed. The anvil of the EEA 29 mm stapler was placed in the proximal sigmoid colon. The EEA stapler was placed in the distal sigmoid colon and the spike was deployed in the antimesenteric side. The stapler was mated without twisting or tension. The enterotomy was then closed with a TA 60 stapler. The abdomen was irrigated with 4 liters of saline to clean out the residual abscess cavity.
An ileostomy aperture was created by making a circular incision in a previously marked stoma location in the right lower quadrant. The anterior fascia was opened longitudinally. The rectus muscle was split and the posterior fascia opened longitudinally to allow two fingers. The terminal ileum was delivered without twisting or tension.
The fascia was closed with running #1 PDS. Interrupted 0 vicryl stitches were placed as internal retention sutures.
The incision was irrigated and the skin closed with staples and covered.
The ileum was opened in matured in brooke fashion taking full thickness bites of ileum followed by a serosal bite and then a dermal bite circumferentially.
Stoma appliance was then applied.
Please help me with coding this report. I dont believe that the Dr. is correct in his coding.
Thanks!