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Lap sigmoid resection with end-to-end anastomosis with Appendectomy
I would appreciate input on how to code this surgery. Thank you!
Preop and Postop diagnosis: Chronic Diverticulitis
Procedure(s) performed: 1. Laparoscopic sigmoid resection with end-to-end stapled anastomosis, 2. Laparoscopic complete mobilization of the splenic flexure, 3. Appendectomy
Specimens: sigmoid colon
Findings: two foci of wall thickening consistent with diverticulitis, the most distal area exhibits marked angulation of the colon. Long appendix with narrow base, wider mid portion.
Details of procedure: After obtaining informed consent the patient was taken to the operating room, placed in a supine position and then underwent induction of general anesthesia. she received antibiotics preoperatively and then was positioned in a low modified lithotomy position with the right arm tucked. All pressure points were well padded. A foley catheter was placed and the abdomen was prepped and draped in standard, sterile surgical fashion.
An 8cm lower midline incision was created with a skin knife and electrocautery was used to dissect down to the fascia which was carefully opened. With one hand inside the abdomen to provide a guide and backdrop and additional 5mm port was placed in the supraumbilical position. The hand port was placed in the lower incision and a 5mm 30 degree camera was inserted into the abdomen. The abdomen was inspected and findings as above were encountered. An additional 5mm working port was placed under direct vision in the left lower quadrant.
The sigmoid colon was grasped through the hand port and retracted laterally. The white line of Toldt was incised along its length toward the spleen. The lateral attachments of the colon were taken down with a combination of Ligasure and blunt dissection. I then changed focus to the transverse colon and entered the lesser sack in the plane between the greater omentum and the colon. This plane was developed towards the splenic flexure., completely mobilizing the flexure and left colon.
Attention was then turned toward the sigmoid colon. Lateral attachments of sigmoid were carefully dissected off the pelvic sidewall. The left ureter was identified and carefully preserved. The mesentery of the left colon was then divided. The IMA and IMV were divided with the LigaSure and then an endoloop was placed over the stalks. The peritoneum overlying the lateral aspects of the distal sigmoid and upper rectum were incised with electrocautery and LigaSure parallel to the bowel. The upper rectum, identified by the absence of tinea coli was identified. The mesorectum at this point was dissected bluntly off the bowel and the mesorectum was divided with judicious use of Ligasure and ties where appropriate. The bowel was then transected at the top of the rectum using a green load in a 35mm curvilinear stapler. The pelvis was observed and irrigated and found to be hemostatic
The proximal resection margin was chosen at an area in the descending/proximal sigmoid which would reach without tension to the top of the rectum, had and excellent blood supply, and was clear of inflammatory changes. The bowel was divided and the specimen passed off the field. A 2-0 proline pursestring was placed and the anvil of a 31mm EEA stapler was passed, per anus to the proximal end of the rectal stump. The spike was advanced at the center of the staple line and coupled with the anvil. The bowel was checked for twisting and was found to be appropriately positioned. The stapler was then closed and fired, resulting in two complete tissue rings. A proctoscope was then inserted per anus and the rectum and colon was insulated while submerged in saline. No leak was observed during the air test.
The anterior aspect of the anastomosis was oversewn with interrupted 3-0 vicryl sutures.
The appendix was considered high risk for future appendicitis and was removed. Ligasure for mesoappendix, GIA stapler, 3-0 vicryl lembert sutures.
Feeling comfortable with a tension free, well vascularized anastomosis we elected to close....
I would appreciate input on how to code this surgery. Thank you!
Preop and Postop diagnosis: Chronic Diverticulitis
Procedure(s) performed: 1. Laparoscopic sigmoid resection with end-to-end stapled anastomosis, 2. Laparoscopic complete mobilization of the splenic flexure, 3. Appendectomy
Specimens: sigmoid colon
Findings: two foci of wall thickening consistent with diverticulitis, the most distal area exhibits marked angulation of the colon. Long appendix with narrow base, wider mid portion.
Details of procedure: After obtaining informed consent the patient was taken to the operating room, placed in a supine position and then underwent induction of general anesthesia. she received antibiotics preoperatively and then was positioned in a low modified lithotomy position with the right arm tucked. All pressure points were well padded. A foley catheter was placed and the abdomen was prepped and draped in standard, sterile surgical fashion.
An 8cm lower midline incision was created with a skin knife and electrocautery was used to dissect down to the fascia which was carefully opened. With one hand inside the abdomen to provide a guide and backdrop and additional 5mm port was placed in the supraumbilical position. The hand port was placed in the lower incision and a 5mm 30 degree camera was inserted into the abdomen. The abdomen was inspected and findings as above were encountered. An additional 5mm working port was placed under direct vision in the left lower quadrant.
The sigmoid colon was grasped through the hand port and retracted laterally. The white line of Toldt was incised along its length toward the spleen. The lateral attachments of the colon were taken down with a combination of Ligasure and blunt dissection. I then changed focus to the transverse colon and entered the lesser sack in the plane between the greater omentum and the colon. This plane was developed towards the splenic flexure., completely mobilizing the flexure and left colon.
Attention was then turned toward the sigmoid colon. Lateral attachments of sigmoid were carefully dissected off the pelvic sidewall. The left ureter was identified and carefully preserved. The mesentery of the left colon was then divided. The IMA and IMV were divided with the LigaSure and then an endoloop was placed over the stalks. The peritoneum overlying the lateral aspects of the distal sigmoid and upper rectum were incised with electrocautery and LigaSure parallel to the bowel. The upper rectum, identified by the absence of tinea coli was identified. The mesorectum at this point was dissected bluntly off the bowel and the mesorectum was divided with judicious use of Ligasure and ties where appropriate. The bowel was then transected at the top of the rectum using a green load in a 35mm curvilinear stapler. The pelvis was observed and irrigated and found to be hemostatic
The proximal resection margin was chosen at an area in the descending/proximal sigmoid which would reach without tension to the top of the rectum, had and excellent blood supply, and was clear of inflammatory changes. The bowel was divided and the specimen passed off the field. A 2-0 proline pursestring was placed and the anvil of a 31mm EEA stapler was passed, per anus to the proximal end of the rectal stump. The spike was advanced at the center of the staple line and coupled with the anvil. The bowel was checked for twisting and was found to be appropriately positioned. The stapler was then closed and fired, resulting in two complete tissue rings. A proctoscope was then inserted per anus and the rectum and colon was insulated while submerged in saline. No leak was observed during the air test.
The anterior aspect of the anastomosis was oversewn with interrupted 3-0 vicryl sutures.
The appendix was considered high risk for future appendicitis and was removed. Ligasure for mesoappendix, GIA stapler, 3-0 vicryl lembert sutures.
Feeling comfortable with a tension free, well vascularized anastomosis we elected to close....
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