cpccoder2008
True Blue
I think because the op report is so long im getting myself very confused. Can someone please help me ? I'm coming up with 46.20 and 45.93 but i'm not sure that is correct.
Thanks
Midline incision was made. The patient had obvious enteric contents within the abdomen. Abdomen was explored. Sigmoid colon mass could be found at the tattoo area. It was roughly 2 to 3cm in size. The patient had obvious injury to the cecum. The patient had a very thin-walled cecum. The loop of small bowel actually was adherent to the cecum and there was cloudy purulent fluid between the cecum and the loop of small bowel, which was adherent to it. It appeared that the cecum had likely ruptured and the small bowel was _____ the process. The area of the enteric contents was throughout the abdomen, especially underneath the diaphragms bilaterally as well as throughout the abdomen and pelvis. There was fibrinous exudate throughout the abdomen as well as in the pelvis. Attention was turned towards the cecum initially. The white line of Toldt on the right was incised, thus mobilizing the terminal ileum, cecum and hepatic flexure. The omentum was mobilized off the proximal transverse colon. In this way, the colon was isolated. The ileocolic artery was taken between clamps, divided and ligated with 0 silk sutures. The 0 silk sutures were doubly ligated the base. Care was taken to identify the _____ prior to that and mobilize it posteriorly. Next, the site was chosen for the proximal transection line. This was in the terminal ileum. Mesentery was taken between clamps, divided and ligated with 0 Vicryl sutures. Next, site was chosen for distal transection line. This was in the mid to proximal transverse colon. Mesentery was taken between clamps, divided and ligated with 0 Vicryl sutures. GIA-80 stapler was used to transect the small bowel and the colon in these areas. The colon was opened and the polyp was noted to be partially excised. There was still residual polyp in the cecum. There was 2.5cm area of denuded tissue, which was very thin walled, which was the area where the polyp likely was removed. Next, attention turned towards the sigmoid colon. The sigmoid colon was mobilized. Left ureter was identified and swept posteriorly. The dissection continued in the descending colon and splenic flexure was mobilized. The omentum was mobilized off the distal transverse colon. In this way, full mobilization of the left colon was performed. Next, the inferior mesenteric artery was taken between clamps and ligated with 0 silk sutures, 0 silk sutures were doubly ligated. Site was chosen for distal transection line. This was in the distal sigmoid proximal rectum. Mesentery was taken between clamps and ligated with 0 silk sutures. The radial load of the Endo-GIA was used to divide the rectum at this point. Next, the site was chosen for proximal transection line. This was at least 10cm proximal to the tattoo mark. Mesentery was taken between clamps, ligated with 0 Vicryl sutures. GIA-80 stapler used to transect the bowel here. The specimen was opened and the mass was noted. Next, the patient was given an ampule of glucagon. The site was chosen for the proximal transection line. Mesentery was taken between clamps, divided with 2-0 Vicryl sutures. Pursestring clamp was placed across the proximal colon. A 2-0 nylon suture was used to create the pursestring. The staple line was excised. Site was used to size the colon. A 28 EEA anvil was placed in the proximal colon and sutured with 2-0 nylon suture. Next, the 28 EEA stapler was brought from below. Spike was advanced through the staple line. The mesentery was noted to be not twisted and oriented correctly. The two ends were then connected and coapted. Stapler was fired. Two complete anastomotic rings were noted. Anastomosis tested underwater. No bubbling was noted. Interrupted 2-0 silk sutures used to reinforce the anastomosis. Next, the entire abdomen was irrigated with copious amounts of saline. The abdomen was irrigated with at least 8L of saline by the end of the case. Next, a side-to-side functional end-to-end anastomosis was performed in the following fashion. The antimesenteric corner of each of bowel was excised. The ileum was anastomosed to the mid transverse colon. The antimesenteric corner of each bowel was excised. GIA 80 stapler was used to create a side-to-side functional and end-to-end anastomosis. The 3-0 silk sutures were used to buttress the staple line. The 3-0 silk sutures were used to approximate the enterotomy created by the stapler. TA-60 stapler for thick tissue load was used to staple off the enterotomy created by the stapler. Next, gloves were changed. The entire abdomen was irrigated with copious amounts of saline. Counts were correct for needle, sponge and instruments prior to closure. Fibrin glue was used to seal both the anastomosis. Small bowel was run. It should be noted that prior to the anastomosis after the antimesenteric corner of the small bowel incised, a Pooles sucker was placed in the small bowel and no enteric contents were milked back and suctioned out. Prior to that, the enteric contents were milked into the stomach and removed that way as well. This allowed decompression of the entire small bowel. The small bowel was dilated all the way to the area of the ileocecal area. However, it was less dilated in the most distal terminal ileum. It appeared that the area where the terminal ileum was adherent to the cecum was where the dilated bowel started and extended proximally. The bowel was placed back in anatomic position. Ureters were found to be intact. Next, a site was chosen for the ileostomy. Ileostomy was chosen because of the degree of contamination. Circular aperture of skin was excised right lower quadrant. The anterior sheath was scored longitudinally. Muscle-splitting technique was used to split the muscle. Posterior sheath was incised longitudinally. Site was chosen for the ileostomy. Space was made between the small bowel and the mesentery. Distal end was tagged with 3-0 silk sutures. The distal end would be the superior portion of the small bowel. The inferior portion was more proximal. The small bowel was brought up into the incision. The distal end had been tagged with the silk suture. Next, several sheets of Seprafilm were placed in the abdomen. A 19 Blake drain was brought through the left lower quadrant and secured with 2-0 nylon suture. It was placed in the pelvis. Posterior sheath was closed using #1 Vicryl in running continuous fashion. Each layer was irrigated between closures. A #1 PDS II was used to close the fascia in running continuous fashion nd staples to close the skin incisions. Next, the ileostomy was matured in a Brooke fashion. The distal side of the small bowel loops was incised transversely. A 3-0 Vicryl sutures were used to create a Brooke loop ileostomy in an interrupted fashion. Stomal appliance was placed in the stoma after Tegaderm and Telfa placed on the incision. The patient tolerated the procedure well. No complications. Estimated blood loss is less than 150mL.
Thanks
Midline incision was made. The patient had obvious enteric contents within the abdomen. Abdomen was explored. Sigmoid colon mass could be found at the tattoo area. It was roughly 2 to 3cm in size. The patient had obvious injury to the cecum. The patient had a very thin-walled cecum. The loop of small bowel actually was adherent to the cecum and there was cloudy purulent fluid between the cecum and the loop of small bowel, which was adherent to it. It appeared that the cecum had likely ruptured and the small bowel was _____ the process. The area of the enteric contents was throughout the abdomen, especially underneath the diaphragms bilaterally as well as throughout the abdomen and pelvis. There was fibrinous exudate throughout the abdomen as well as in the pelvis. Attention was turned towards the cecum initially. The white line of Toldt on the right was incised, thus mobilizing the terminal ileum, cecum and hepatic flexure. The omentum was mobilized off the proximal transverse colon. In this way, the colon was isolated. The ileocolic artery was taken between clamps, divided and ligated with 0 silk sutures. The 0 silk sutures were doubly ligated the base. Care was taken to identify the _____ prior to that and mobilize it posteriorly. Next, the site was chosen for the proximal transection line. This was in the terminal ileum. Mesentery was taken between clamps, divided and ligated with 0 Vicryl sutures. Next, site was chosen for distal transection line. This was in the mid to proximal transverse colon. Mesentery was taken between clamps, divided and ligated with 0 Vicryl sutures. GIA-80 stapler was used to transect the small bowel and the colon in these areas. The colon was opened and the polyp was noted to be partially excised. There was still residual polyp in the cecum. There was 2.5cm area of denuded tissue, which was very thin walled, which was the area where the polyp likely was removed. Next, attention turned towards the sigmoid colon. The sigmoid colon was mobilized. Left ureter was identified and swept posteriorly. The dissection continued in the descending colon and splenic flexure was mobilized. The omentum was mobilized off the distal transverse colon. In this way, full mobilization of the left colon was performed. Next, the inferior mesenteric artery was taken between clamps and ligated with 0 silk sutures, 0 silk sutures were doubly ligated. Site was chosen for distal transection line. This was in the distal sigmoid proximal rectum. Mesentery was taken between clamps and ligated with 0 silk sutures. The radial load of the Endo-GIA was used to divide the rectum at this point. Next, the site was chosen for proximal transection line. This was at least 10cm proximal to the tattoo mark. Mesentery was taken between clamps, ligated with 0 Vicryl sutures. GIA-80 stapler used to transect the bowel here. The specimen was opened and the mass was noted. Next, the patient was given an ampule of glucagon. The site was chosen for the proximal transection line. Mesentery was taken between clamps, divided with 2-0 Vicryl sutures. Pursestring clamp was placed across the proximal colon. A 2-0 nylon suture was used to create the pursestring. The staple line was excised. Site was used to size the colon. A 28 EEA anvil was placed in the proximal colon and sutured with 2-0 nylon suture. Next, the 28 EEA stapler was brought from below. Spike was advanced through the staple line. The mesentery was noted to be not twisted and oriented correctly. The two ends were then connected and coapted. Stapler was fired. Two complete anastomotic rings were noted. Anastomosis tested underwater. No bubbling was noted. Interrupted 2-0 silk sutures used to reinforce the anastomosis. Next, the entire abdomen was irrigated with copious amounts of saline. The abdomen was irrigated with at least 8L of saline by the end of the case. Next, a side-to-side functional end-to-end anastomosis was performed in the following fashion. The antimesenteric corner of each of bowel was excised. The ileum was anastomosed to the mid transverse colon. The antimesenteric corner of each bowel was excised. GIA 80 stapler was used to create a side-to-side functional and end-to-end anastomosis. The 3-0 silk sutures were used to buttress the staple line. The 3-0 silk sutures were used to approximate the enterotomy created by the stapler. TA-60 stapler for thick tissue load was used to staple off the enterotomy created by the stapler. Next, gloves were changed. The entire abdomen was irrigated with copious amounts of saline. Counts were correct for needle, sponge and instruments prior to closure. Fibrin glue was used to seal both the anastomosis. Small bowel was run. It should be noted that prior to the anastomosis after the antimesenteric corner of the small bowel incised, a Pooles sucker was placed in the small bowel and no enteric contents were milked back and suctioned out. Prior to that, the enteric contents were milked into the stomach and removed that way as well. This allowed decompression of the entire small bowel. The small bowel was dilated all the way to the area of the ileocecal area. However, it was less dilated in the most distal terminal ileum. It appeared that the area where the terminal ileum was adherent to the cecum was where the dilated bowel started and extended proximally. The bowel was placed back in anatomic position. Ureters were found to be intact. Next, a site was chosen for the ileostomy. Ileostomy was chosen because of the degree of contamination. Circular aperture of skin was excised right lower quadrant. The anterior sheath was scored longitudinally. Muscle-splitting technique was used to split the muscle. Posterior sheath was incised longitudinally. Site was chosen for the ileostomy. Space was made between the small bowel and the mesentery. Distal end was tagged with 3-0 silk sutures. The distal end would be the superior portion of the small bowel. The inferior portion was more proximal. The small bowel was brought up into the incision. The distal end had been tagged with the silk suture. Next, several sheets of Seprafilm were placed in the abdomen. A 19 Blake drain was brought through the left lower quadrant and secured with 2-0 nylon suture. It was placed in the pelvis. Posterior sheath was closed using #1 Vicryl in running continuous fashion. Each layer was irrigated between closures. A #1 PDS II was used to close the fascia in running continuous fashion nd staples to close the skin incisions. Next, the ileostomy was matured in a Brooke fashion. The distal side of the small bowel loops was incised transversely. A 3-0 Vicryl sutures were used to create a Brooke loop ileostomy in an interrupted fashion. Stomal appliance was placed in the stoma after Tegaderm and Telfa placed on the incision. The patient tolerated the procedure well. No complications. Estimated blood loss is less than 150mL.