ErinSwanson
New
Hello,
I have a patient that has a history of previous anastomosis placement. She was seen more recently and from my understanding she had a partial colectomy of cecum with removal of terminal ileum, but instead of having an ileocolostomy--she had an ileostomy placement. I am unsure on what code to choose for this procedure. Thanks in advance for your help.
I made an incision in the old scar site above the umbilicus down to just below the umbilicus. I dissected down to the anterior fascia. This was opened. I dissected the omentum off the anterior abdominal wall. Once this was performed I placed a large Alexis within the abdomen. I was able to see the ileocolic anastomosis. This is firm and with inflammatory bowel disease. There is a clear demarcation where the small bowel has no more obvious Crohn's. Around the bowel towards the ligament of Treitz but did not reach it fully due to the smaller incision admitted. The entire small bowel looked relatively free of Crohn's disease except for the area that has surgical intention today. I dissected the colon off the hepatic flexure. I then used clamps and ties and a LigaSure to dissect the colon. There is a demarcation of creeping fat. I used this as a marker for resection. I frozen the millimeter blue load GIA stapler across this once a dissected this out. The I then went to the small bowel and went to the area of normal small bowel and resected it. She probably lost 20 cm of small intestine. Some of her small intestine was adhesed to itself with creeping fat. I dissected this area out and fired a stapler (80 mm blue load GIA) across this. The terminal ileum mesentery was taken with clamps and ties and the LigaSure. The specimen was sent to the back table.
I irrigated the abdomen. A small bleeders were ligated. The right side of the abdomen was inspected. I did look at the abdomen preoperatively to determine the location of ileostomy and she and I discussed that. I used this location and I made a small circular incision of skin. I dissected the fat using 2 Army-Navy's. We got down to the anterior fascia. I made a cruciate incision in the anterior fascia. She had above 5 cm of adipose tissue. I then split the rectus muscles and made up posterior fascia incision in a cruciate manner. I was able to place 2 fingers within this. I then brought the small bowel up through this. He had good length but the mesentery was so heavy and thick that it was going to be hard to broke that mesenteric portion. I did some dissection of the mesentery within it but I wanting to maintain the balance of keeping vascular blood supply. Once this was performed I felt that enough length and did not need to do any more intra-abdominal he. The abdomen was washed out. We closed the fascia using #1 PDS sutures. There is an area of hernia that was thick and scarred. I dissected back to the fascia. I then was able to close the fascia with two #1 PDS sutures. Running fashion. I irrigated subcutaneous tissues. I used a 3-0 Vicryl in the subcutaneous tissues. I closed the skin with 4-0 Monocryl. This was covered. I then matured the ileostomy in a normal Brooke fashion. At the superior aspect of the ileostomy it was difficult to Brooke due to the thick and wide mesentery. This was more of a flatter part of the stoma wall the rest of the ileostomy which was three quarters circumferential was protuberant and with a nice Brooke height. An appliance was placed and dressings were placed in the midline incision. No significant complications. Class II case. 100 mL EBL. This is due to the thick foreshortened mesentery that required both ties and LigaSure to maintain hemostasis.
I have a patient that has a history of previous anastomosis placement. She was seen more recently and from my understanding she had a partial colectomy of cecum with removal of terminal ileum, but instead of having an ileocolostomy--she had an ileostomy placement. I am unsure on what code to choose for this procedure. Thanks in advance for your help.
I made an incision in the old scar site above the umbilicus down to just below the umbilicus. I dissected down to the anterior fascia. This was opened. I dissected the omentum off the anterior abdominal wall. Once this was performed I placed a large Alexis within the abdomen. I was able to see the ileocolic anastomosis. This is firm and with inflammatory bowel disease. There is a clear demarcation where the small bowel has no more obvious Crohn's. Around the bowel towards the ligament of Treitz but did not reach it fully due to the smaller incision admitted. The entire small bowel looked relatively free of Crohn's disease except for the area that has surgical intention today. I dissected the colon off the hepatic flexure. I then used clamps and ties and a LigaSure to dissect the colon. There is a demarcation of creeping fat. I used this as a marker for resection. I frozen the millimeter blue load GIA stapler across this once a dissected this out. The I then went to the small bowel and went to the area of normal small bowel and resected it. She probably lost 20 cm of small intestine. Some of her small intestine was adhesed to itself with creeping fat. I dissected this area out and fired a stapler (80 mm blue load GIA) across this. The terminal ileum mesentery was taken with clamps and ties and the LigaSure. The specimen was sent to the back table.
I irrigated the abdomen. A small bleeders were ligated. The right side of the abdomen was inspected. I did look at the abdomen preoperatively to determine the location of ileostomy and she and I discussed that. I used this location and I made a small circular incision of skin. I dissected the fat using 2 Army-Navy's. We got down to the anterior fascia. I made a cruciate incision in the anterior fascia. She had above 5 cm of adipose tissue. I then split the rectus muscles and made up posterior fascia incision in a cruciate manner. I was able to place 2 fingers within this. I then brought the small bowel up through this. He had good length but the mesentery was so heavy and thick that it was going to be hard to broke that mesenteric portion. I did some dissection of the mesentery within it but I wanting to maintain the balance of keeping vascular blood supply. Once this was performed I felt that enough length and did not need to do any more intra-abdominal he. The abdomen was washed out. We closed the fascia using #1 PDS sutures. There is an area of hernia that was thick and scarred. I dissected back to the fascia. I then was able to close the fascia with two #1 PDS sutures. Running fashion. I irrigated subcutaneous tissues. I used a 3-0 Vicryl in the subcutaneous tissues. I closed the skin with 4-0 Monocryl. This was covered. I then matured the ileostomy in a normal Brooke fashion. At the superior aspect of the ileostomy it was difficult to Brooke due to the thick and wide mesentery. This was more of a flatter part of the stoma wall the rest of the ileostomy which was three quarters circumferential was protuberant and with a nice Brooke height. An appliance was placed and dressings were placed in the midline incision. No significant complications. Class II case. 100 mL EBL. This is due to the thick foreshortened mesentery that required both ties and LigaSure to maintain hemostasis.