ksb0211
Guest
Hey, all! I'm just hoping for a little outside opinion on a case. I would like to verify not only the main code, but CCI edit info as well. Thanks to all that check this out and offer their thoughts....
PROCEDURE/OPERATION
1. Laparoscopic takedown of splenic flexure.
2. Hand-assisted left hemicolectomy.
3. Removal of rectosigmoid stent.
4. Bilateral salpingooophorectomy.
5. Repair of 1.5 cm umbilical hernia.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room and after attainment of sufficient general anesthesia she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. A low suprapubic incision was made about 9 cm in length. We placed a GelPort into position, then entering our hand we placed two more ports, one through the umbilical hernia which we noted superiorly, and another one laterally in the left lower quadrant. We took down the white line of Toldt using the Harmonic scalpel, then came around the splenic flexure mobilizing the colon downward. This was easily affected and there was no significant bleeding from any of our operative sites. Once that was done we then brought our incision, using the Harmonic down into the pelvis, identified the ureters bilateral and they were preserved. In the course of this dissection we could see that this tumor was very close to the ovaries, and one of them actually was in the way of our dissection so we took the left side down, taking down the ovarian vessels between clamps, then using the Harmonic scalpel coming across the round ligament, then up on to the top of the uterus using a suture ligature at that level of 2-0 silk. Similar technique was carried out on the opposite side removing both the tube an ovary on both sides. At this point we developed our exposure, dissected anteriorly. There was a lot of edema in this colon as one might expect. She was obstructed for a while, and then we had the stent in place. We dissected the anterior bladder, behind the bladder in the retrovesical space of Douglas, dissected down. Actually that dissection went very well. What we did in order to get the stent removed, we made an incision on the sigmoid side of the colon, identified the end of the stent and placed two #1 Prolene sutures that we left great big long tails on, and we made one suture go from 12 o'clock to 6 o'clock and the other suture went from 3 o'clock to 9 o'clock. We then took these loops of suture and we ran them back through a 36-French chest tube so that we had the sutures passing up through the chest tube. We then fitted the end of the well-lubricated stent on to the end of the chest tube and then pulled those stitches down and the effect was to bring the end of the stent into the chest tube and then by advancing the chest tube over the stent we collapsed the stent pulling the stent back up as we came and the stent came up with absolutely no difficulty whatsoever. Having done that we had packed off the abdomen before we did it, we closed the rent in the distal sigmoid with 2-0 figure-of-eight silks, irrigated the operative field at this point then aspirated. There was really no spillage whatsoever. We then proceed with the remainder of the operation and eventually we got to the point where we mobilized the colon, took down the lateral stalks. Most of this was done with the Harmonic scalpel, some of it was done with 2-0 silk ties. We had previously divided the colon proximally using a GIA, and then as we carried our dissection down, we had initially gone through the sigmoid but came down with the Harmonic scalpel. We then came through the mesocolon and then ligated that off with 2-0 silks where the left colic vessels were found. Once that was done we had mobilized the colon. The assistant surgeon went up and with digital examination made sure we had clearance on the tumor which we did. We placed a Contour stapling device into the pelvis and fired it leaving a rectal stump of about 5 cm. Our margin in vivo was about 3 cm on this tumor, we knew that we would pick up perhaps another centimeter when we fired the CEEA. We did that, we sized out the colon to 28 mm, and then introduced through the rectum a CEEA with a sharpened obturator, brought it through the staple line connected the end of the sigmoid through which we had placed the anvil on to the stapler, brought it down to tolerances, fired it, and bringing back two complete donuts. Once that was done we placed a clamp distally, went up with the sigmoidoscope, and insufflated into the colon and proved that we had an air-tight anastomosis. The anastomosis itself looked quite good. We placed a 10 mm Jackson-Pratt into the pelvis, and then irrigated again and aspirated the fluid, then reapproximated some of the surrounding peritoneum to the colon so we would not get any entrapped small bowel, then covered the entire operative field with surrounding omentum, then turned our attention to closure. We went back up to the port site which had gone through the umbilical hernia, extended it, took down the preperitoneal fat in the sac in that area and closed that with a figure-of-eight suture of #1 Prolene and we ducked the knot internally, that carried out the repair. Then we closed the wound with double-stranded #1 PDS, followed by irrigation, followed by 3-0 Vicryl, followed by skin staples. The patient tolerated the procedure quite well.
PROCEDURE/OPERATION
1. Laparoscopic takedown of splenic flexure.
2. Hand-assisted left hemicolectomy.
3. Removal of rectosigmoid stent.
4. Bilateral salpingooophorectomy.
5. Repair of 1.5 cm umbilical hernia.
DESCRIPTION OF PROCEDURE
The patient was brought to the operating room and after attainment of sufficient general anesthesia she was pretreated with antibiotics and prepped and draped in the usual sterile fashion. A low suprapubic incision was made about 9 cm in length. We placed a GelPort into position, then entering our hand we placed two more ports, one through the umbilical hernia which we noted superiorly, and another one laterally in the left lower quadrant. We took down the white line of Toldt using the Harmonic scalpel, then came around the splenic flexure mobilizing the colon downward. This was easily affected and there was no significant bleeding from any of our operative sites. Once that was done we then brought our incision, using the Harmonic down into the pelvis, identified the ureters bilateral and they were preserved. In the course of this dissection we could see that this tumor was very close to the ovaries, and one of them actually was in the way of our dissection so we took the left side down, taking down the ovarian vessels between clamps, then using the Harmonic scalpel coming across the round ligament, then up on to the top of the uterus using a suture ligature at that level of 2-0 silk. Similar technique was carried out on the opposite side removing both the tube an ovary on both sides. At this point we developed our exposure, dissected anteriorly. There was a lot of edema in this colon as one might expect. She was obstructed for a while, and then we had the stent in place. We dissected the anterior bladder, behind the bladder in the retrovesical space of Douglas, dissected down. Actually that dissection went very well. What we did in order to get the stent removed, we made an incision on the sigmoid side of the colon, identified the end of the stent and placed two #1 Prolene sutures that we left great big long tails on, and we made one suture go from 12 o'clock to 6 o'clock and the other suture went from 3 o'clock to 9 o'clock. We then took these loops of suture and we ran them back through a 36-French chest tube so that we had the sutures passing up through the chest tube. We then fitted the end of the well-lubricated stent on to the end of the chest tube and then pulled those stitches down and the effect was to bring the end of the stent into the chest tube and then by advancing the chest tube over the stent we collapsed the stent pulling the stent back up as we came and the stent came up with absolutely no difficulty whatsoever. Having done that we had packed off the abdomen before we did it, we closed the rent in the distal sigmoid with 2-0 figure-of-eight silks, irrigated the operative field at this point then aspirated. There was really no spillage whatsoever. We then proceed with the remainder of the operation and eventually we got to the point where we mobilized the colon, took down the lateral stalks. Most of this was done with the Harmonic scalpel, some of it was done with 2-0 silk ties. We had previously divided the colon proximally using a GIA, and then as we carried our dissection down, we had initially gone through the sigmoid but came down with the Harmonic scalpel. We then came through the mesocolon and then ligated that off with 2-0 silks where the left colic vessels were found. Once that was done we had mobilized the colon. The assistant surgeon went up and with digital examination made sure we had clearance on the tumor which we did. We placed a Contour stapling device into the pelvis and fired it leaving a rectal stump of about 5 cm. Our margin in vivo was about 3 cm on this tumor, we knew that we would pick up perhaps another centimeter when we fired the CEEA. We did that, we sized out the colon to 28 mm, and then introduced through the rectum a CEEA with a sharpened obturator, brought it through the staple line connected the end of the sigmoid through which we had placed the anvil on to the stapler, brought it down to tolerances, fired it, and bringing back two complete donuts. Once that was done we placed a clamp distally, went up with the sigmoidoscope, and insufflated into the colon and proved that we had an air-tight anastomosis. The anastomosis itself looked quite good. We placed a 10 mm Jackson-Pratt into the pelvis, and then irrigated again and aspirated the fluid, then reapproximated some of the surrounding peritoneum to the colon so we would not get any entrapped small bowel, then covered the entire operative field with surrounding omentum, then turned our attention to closure. We went back up to the port site which had gone through the umbilical hernia, extended it, took down the preperitoneal fat in the sac in that area and closed that with a figure-of-eight suture of #1 Prolene and we ducked the knot internally, that carried out the repair. Then we closed the wound with double-stranded #1 PDS, followed by irrigation, followed by 3-0 Vicryl, followed by skin staples. The patient tolerated the procedure quite well.
