Pebbles1218
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Sometimes it's confusing to me on rt colon resections because the code 44160 includes removal of terminal ileum or part of and the doctor does not always remove any of the terminal ileum. If anyone could look at the this operative report and path and tell me how you would code it I would appreciate it
Thanks
Operative report:
DETAILS OF SURGERY: Patient was brought into the operating room,
placed in supine position, received anesthesia. Abdomen was
prepped. We made a midline incision through skin, subcutaneous
tissues, fascia, entered the abdominal cavity. We mobilized the
right colon all the way over to the middle colic vessels. We
divided the colon just to the right of the middle colic vessels,
carried our dissection down the mesentery to the ileocolic
vessels. We then divided the terminal ileum and carried our
dissection of the mesentery up the inferior aspect, paying
particular attention to the position of the ureter and the
duodenum at all times. We placed clamps across the ileocolic
vessel and divided that structure, oversewed it using a figure-of-
eight Vicryl stitch. We then closed the mesenteric defect with 3-
0 Vicryl interrupted sutures and did a hand-sewn end-to-end
anastomosis using 3-0 Vicryl interrupted sutures. We checked the
anastomosis, found no evidence of leakage and no evidence of
ischemia. We then irrigated and obtained hemostasis. We closed
the midline fascia with #1 looped PDS, closed the skin with
surgical staples, placed sterile gauze and paper tape over that.
The patient tolerated procedure well.
path report
DIAGNOSIS:
Colon, right, resection:
- Tubular adenoma, 2.5 x 2.5 cm.
- No in-situ or invasive carcinoma identified.
- Unremarkable appendix.
- Shave resection margins free of adenomatous change.
- Seventeen lymph nodes; no metastatic carcinoma identified (0/17).
COMMENT: The diagnosis rendered is based upon gross and microscopic
examination.
CLINICAL HISTORY/DX: 76-yr-old male with history of prostate cancer.
For colon resection.
GROSS:
1. Right colon
Received is a container labeled with the patient's name and "1 right
colon". Present in the container is a specimen consistent with the
label. The bowel has been previously opened. The colon measures 27 x
3.5 x 2.5 cm. A moderate amount of adipose tissue is present. Both
margins are open. The small bowel has a length of 3.5 cm. Identified
4 cm. from the ileocecal valve and 20 cm. from the distal margin is a
sessile polyp which has been previously sectioned into. The polyp
measures 2.5 x 2.5 cm. The adipose tissue is removed and placed in
Dissect-Aid. The appendix has a length of 4.8 cm. and ranges in
diameter from 0.5 to 0.7 cm. Sectioning the
appendix reveals no gross lesions. The sessile polyp is pinned to wax
for fixation. Sectioning reveals no invasive tumor grossly. No
additional polyps, masses or diverticulosis is appreciated. Summary of
sections: "1A" - proximal margin, "1B" - distal margin, "1C" -
appendix, "1D" - "1H" - sessile polyp, "1I" - "1K" - small nodes
Thanks
Operative report:
DETAILS OF SURGERY: Patient was brought into the operating room,
placed in supine position, received anesthesia. Abdomen was
prepped. We made a midline incision through skin, subcutaneous
tissues, fascia, entered the abdominal cavity. We mobilized the
right colon all the way over to the middle colic vessels. We
divided the colon just to the right of the middle colic vessels,
carried our dissection down the mesentery to the ileocolic
vessels. We then divided the terminal ileum and carried our
dissection of the mesentery up the inferior aspect, paying
particular attention to the position of the ureter and the
duodenum at all times. We placed clamps across the ileocolic
vessel and divided that structure, oversewed it using a figure-of-
eight Vicryl stitch. We then closed the mesenteric defect with 3-
0 Vicryl interrupted sutures and did a hand-sewn end-to-end
anastomosis using 3-0 Vicryl interrupted sutures. We checked the
anastomosis, found no evidence of leakage and no evidence of
ischemia. We then irrigated and obtained hemostasis. We closed
the midline fascia with #1 looped PDS, closed the skin with
surgical staples, placed sterile gauze and paper tape over that.
The patient tolerated procedure well.
path report
DIAGNOSIS:
Colon, right, resection:
- Tubular adenoma, 2.5 x 2.5 cm.
- No in-situ or invasive carcinoma identified.
- Unremarkable appendix.
- Shave resection margins free of adenomatous change.
- Seventeen lymph nodes; no metastatic carcinoma identified (0/17).
COMMENT: The diagnosis rendered is based upon gross and microscopic
examination.
CLINICAL HISTORY/DX: 76-yr-old male with history of prostate cancer.
For colon resection.
GROSS:
1. Right colon
Received is a container labeled with the patient's name and "1 right
colon". Present in the container is a specimen consistent with the
label. The bowel has been previously opened. The colon measures 27 x
3.5 x 2.5 cm. A moderate amount of adipose tissue is present. Both
margins are open. The small bowel has a length of 3.5 cm. Identified
4 cm. from the ileocecal valve and 20 cm. from the distal margin is a
sessile polyp which has been previously sectioned into. The polyp
measures 2.5 x 2.5 cm. The adipose tissue is removed and placed in
Dissect-Aid. The appendix has a length of 4.8 cm. and ranges in
diameter from 0.5 to 0.7 cm. Sectioning the
appendix reveals no gross lesions. The sessile polyp is pinned to wax
for fixation. Sectioning reveals no invasive tumor grossly. No
additional polyps, masses or diverticulosis is appreciated. Summary of
sections: "1A" - proximal margin, "1B" - distal margin, "1C" -
appendix, "1D" - "1H" - sessile polyp, "1I" - "1K" - small nodes
