Please help me!! I have been struggling with coding this Op report for the last 3 days and I'm ready to pull my hair out!! I'm stuck between codes 44143 and 44144. Not sure which code to append. Any assistance is GREATLY appreciated!! Please refer below to the Op note:
PREOPERATIVE DIAGNOSIS: STATUS POST EXPLORATORY LAPAROTOMY WITH TOTAL
COLECTOMY AND BOWEL DISCONTINUITY STATUS POST TOXIC MEGACOLON.
POSTOPERATIVE DIAGNOSIS: STATUS POST EXPLORATORY LAPAROTOMY WITH TOTAL
COLECTOMY AND BOWEL DISCONTINUITY STATUS POST TOXIC MEGACOLON.
OPERATION:
1. EXPLORATORY LAPAROTOMY.
2. ABDOMINAL WASHOUT.
3. SMALL BOWEL RESECTION.
4. ILEOSTOMY CREATION.
5. WITTMANN PATCH PLACEMENT.
ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.
COMPLICATIONS: NONE.
SPECIMENS: APPROXIMATELY 35 CM OF SMALL INTESTINE TO PATHOLOGY.
ESTIMATED BLOOD LOSS: APPROXIMATELY 300 ML.
FLUIDS: APPROXIMATELY 1 L OF CRYSTALLOID AND 250 ML OF ALBUMIN AND 350
ML OF PACKED RED BLOOD CELLS.
DISPOSITION: CRITICALLY ILL, OPEN ABDOMEN WITH WITTMANN PATCH, AND
BLACK SPONGE WOUND VAC AND NEW ILEOSTOMY WITH APPLIANCE APPLIED,
RETURNED TO SURGICAL INTENSIVE CARE UNIT, INTUBATED.
FINDINGS:
1. Diffusely ischemic small bowel with nontransmural necrosis.
2. Excessively bleeding surface tissues.
3. Status post total colectomy.
4. Significant edema of small bowel and other abdominal viscera.
OPERATIVE INDICATIONS:
43-year-old female who originally presented to Medical Center on January 25th, 2023 for myomectomy.
Please refer to the operative report of the Ob/Gyn service at that time.
Unfortunately, her postoperative course was complicated by significant
tachycardia, hypotension, and a near cardiac arrest. The patient was
later found to have toxic megacolon and to be C. difficile positive.
She subsequently underwent a subtotal colectomy with her bowel left in
discontinuity secondary to septic shock and need for further
resuscitation. The patient was then presented to me, and she was taken
to the operating room for ileostomy creation and temporary closure
device placement for the abdominal exploratory laparotomy incision.
Full informed consent was obtained from the patient's mother and after
being properly consented with discussion of the risks and benefits
involved, the patient was taken to the operative suite.
PROCEDURE:
After proper identification and consent, the patient was taken to the
operative suite and placed in the supine position. The patient had a
rectal tube, Foley catheter placed, an endotracheal tube, nasogastric
tube to continuous suction, and an ABThera device in place at her
abdominal incision.
The ABThera was removed. The patient was prepped and draped in the
usual sterile manner with Betadine, and the abdomen was washed out with
2 to 3 L of warm sterile saline. We encountered some fibrinous material
and some bile stained ascites in pockets. There was no purulence, there
was no hemorrhage or blood clot in the abdomen. However, the raw edges
of the abdominal wall began to become bloody during the case.
We turned our attention to running the small bowel from the ileum staple
line all the way to the ligament of Treitz. We did this 2 separate
times and noted several areas of discrete ischemia and some areas of
more global dusky ischemia. There was no transmural ischemia present or
succus coming from the small bowel from any perforations; however, there
were some areas that looked denuded of the small bowel and clearly
appeared to be nearing rupture and perforation. The area of greatest
ischemic concern was the distal ileum and using a soft ruler, I measured
approximately 30 cm of small bowel that would need to be removed
immediately for the ileostomy creation. Additionally, there were
multiple other areas at risk which appeared as if they would become
transmurally ischemic in the next day to 2 days. This would make the
patient have short gut syndrome. Therefore, to allow as much
possibility of recovery, the decision was made to limit the resection at
this time to approximately 30 or 35 cm of the distal ileum.
This was accomplished with an Impact LigaSure and an EndoGIA 60 mm
purple load. The specimen was sent to the pathology for evaluation. We
then created an ileostomy site in the right upper quadrant utilizing the
15 blade and electrocautery. We entered the anterior rectus sheath,
split the muscle, went through the posterior rectus sheath taking care
to protect the bowel within the abdomen. We then used a Babcock clamp
on the staple line to gently bring the ileostomy up through the created
abdominal wall defect. However, as soon as we brought the distal ileum
stapled through the abdominal wall site, it disintegrated
and began leaking succus. We carefully clamped this off, brought the
ileum back into the operative field, and resected an additional 4 to 5
cm to reach viable bowel. We then brought this up again through the
abdominal wall defect that we had created, and this time the staple line
held. At that point, it was time to close the abdomen, and I decided to place
Wittmann patch on either side of the fascial layer.
The Wittmann patch was sewn in with 2-0 Prolene bilaterally in a running
fashion. The patch was appropriately trimmed and then utilized to close
the abdominal anterior wall. We then matured the ostomy utilizing 2-0
Vicryl in a Brooke technique, and additional 2-0 Vicryl were utilized to
fix the ileum to the abdominal wall. We then placed an appliance wafer
over the ileostomy. I then measured a black sponge wound VAC and placed
that in the abdominal wound overlying the Wittmann patch. I also placed
a sterile x-ray cassette over the bowel to protect it further from the
Wittmann patch. Once the black sponge was in place on top of the
Wittmann patch, we secured it and began suction. There was notable
amount of bloody weeping that was suctioned away from the anterior
abdominal wall tissues, and the patient also received a unit of blood
for this loss.
The patient was then taken in critically ill, intubated condition with
the wound VAC functioning, Foley in place, NG tube in place,
endotracheal tube in place, and rectal tube in place, back to the
surgical intensive care unit.
I was scrubbed and present and directly performed and/or supervised all
aspects of this case.
PREOPERATIVE DIAGNOSIS: STATUS POST EXPLORATORY LAPAROTOMY WITH TOTAL
COLECTOMY AND BOWEL DISCONTINUITY STATUS POST TOXIC MEGACOLON.
POSTOPERATIVE DIAGNOSIS: STATUS POST EXPLORATORY LAPAROTOMY WITH TOTAL
COLECTOMY AND BOWEL DISCONTINUITY STATUS POST TOXIC MEGACOLON.
OPERATION:
1. EXPLORATORY LAPAROTOMY.
2. ABDOMINAL WASHOUT.
3. SMALL BOWEL RESECTION.
4. ILEOSTOMY CREATION.
5. WITTMANN PATCH PLACEMENT.
ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.
COMPLICATIONS: NONE.
SPECIMENS: APPROXIMATELY 35 CM OF SMALL INTESTINE TO PATHOLOGY.
ESTIMATED BLOOD LOSS: APPROXIMATELY 300 ML.
FLUIDS: APPROXIMATELY 1 L OF CRYSTALLOID AND 250 ML OF ALBUMIN AND 350
ML OF PACKED RED BLOOD CELLS.
DISPOSITION: CRITICALLY ILL, OPEN ABDOMEN WITH WITTMANN PATCH, AND
BLACK SPONGE WOUND VAC AND NEW ILEOSTOMY WITH APPLIANCE APPLIED,
RETURNED TO SURGICAL INTENSIVE CARE UNIT, INTUBATED.
FINDINGS:
1. Diffusely ischemic small bowel with nontransmural necrosis.
2. Excessively bleeding surface tissues.
3. Status post total colectomy.
4. Significant edema of small bowel and other abdominal viscera.
OPERATIVE INDICATIONS:
43-year-old female who originally presented to Medical Center on January 25th, 2023 for myomectomy.
Please refer to the operative report of the Ob/Gyn service at that time.
Unfortunately, her postoperative course was complicated by significant
tachycardia, hypotension, and a near cardiac arrest. The patient was
later found to have toxic megacolon and to be C. difficile positive.
She subsequently underwent a subtotal colectomy with her bowel left in
discontinuity secondary to septic shock and need for further
resuscitation. The patient was then presented to me, and she was taken
to the operating room for ileostomy creation and temporary closure
device placement for the abdominal exploratory laparotomy incision.
Full informed consent was obtained from the patient's mother and after
being properly consented with discussion of the risks and benefits
involved, the patient was taken to the operative suite.
PROCEDURE:
After proper identification and consent, the patient was taken to the
operative suite and placed in the supine position. The patient had a
rectal tube, Foley catheter placed, an endotracheal tube, nasogastric
tube to continuous suction, and an ABThera device in place at her
abdominal incision.
The ABThera was removed. The patient was prepped and draped in the
usual sterile manner with Betadine, and the abdomen was washed out with
2 to 3 L of warm sterile saline. We encountered some fibrinous material
and some bile stained ascites in pockets. There was no purulence, there
was no hemorrhage or blood clot in the abdomen. However, the raw edges
of the abdominal wall began to become bloody during the case.
We turned our attention to running the small bowel from the ileum staple
line all the way to the ligament of Treitz. We did this 2 separate
times and noted several areas of discrete ischemia and some areas of
more global dusky ischemia. There was no transmural ischemia present or
succus coming from the small bowel from any perforations; however, there
were some areas that looked denuded of the small bowel and clearly
appeared to be nearing rupture and perforation. The area of greatest
ischemic concern was the distal ileum and using a soft ruler, I measured
approximately 30 cm of small bowel that would need to be removed
immediately for the ileostomy creation. Additionally, there were
multiple other areas at risk which appeared as if they would become
transmurally ischemic in the next day to 2 days. This would make the
patient have short gut syndrome. Therefore, to allow as much
possibility of recovery, the decision was made to limit the resection at
this time to approximately 30 or 35 cm of the distal ileum.
This was accomplished with an Impact LigaSure and an EndoGIA 60 mm
purple load. The specimen was sent to the pathology for evaluation. We
then created an ileostomy site in the right upper quadrant utilizing the
15 blade and electrocautery. We entered the anterior rectus sheath,
split the muscle, went through the posterior rectus sheath taking care
to protect the bowel within the abdomen. We then used a Babcock clamp
on the staple line to gently bring the ileostomy up through the created
abdominal wall defect. However, as soon as we brought the distal ileum
stapled through the abdominal wall site, it disintegrated
and began leaking succus. We carefully clamped this off, brought the
ileum back into the operative field, and resected an additional 4 to 5
cm to reach viable bowel. We then brought this up again through the
abdominal wall defect that we had created, and this time the staple line
held. At that point, it was time to close the abdomen, and I decided to place
Wittmann patch on either side of the fascial layer.
The Wittmann patch was sewn in with 2-0 Prolene bilaterally in a running
fashion. The patch was appropriately trimmed and then utilized to close
the abdominal anterior wall. We then matured the ostomy utilizing 2-0
Vicryl in a Brooke technique, and additional 2-0 Vicryl were utilized to
fix the ileum to the abdominal wall. We then placed an appliance wafer
over the ileostomy. I then measured a black sponge wound VAC and placed
that in the abdominal wound overlying the Wittmann patch. I also placed
a sterile x-ray cassette over the bowel to protect it further from the
Wittmann patch. Once the black sponge was in place on top of the
Wittmann patch, we secured it and began suction. There was notable
amount of bloody weeping that was suctioned away from the anterior
abdominal wall tissues, and the patient also received a unit of blood
for this loss.
The patient was then taken in critically ill, intubated condition with
the wound VAC functioning, Foley in place, NG tube in place,
endotracheal tube in place, and rectal tube in place, back to the
surgical intensive care unit.
I was scrubbed and present and directly performed and/or supervised all
aspects of this case.