Can anyone assist in coding the following
Thank you in advance for any assistance
PROCEDURE:
An orogastric tube was initially placed and then, due to
the volume of fluid in her
stomach, converted to a nasogastric tube and eventually
1,300 mL of fluid was removed
through the nasogastric tube. The gross findings are as
described above. After sterilely
prepping and draping the patient in the usual fashion
and a surgical time out was held,
the staples were removed from her original incision in
the left lower quadrant and then
the fascial sutures were transected with Mayo scissors; and
the peritoneal cavity was
then entered with the gross findings as described above.
A self-retaining Balfour
retractor was then placed. Again the gross findings as
described above. Upon noting
where the mostly bilious material was noted in the right
pelvis, the small bowel was run
completely with no evidence of any small bowel rupture or
injury. Eventually it was
noted that the collection was coming from the right
lateral aspect of the anastomosis of
the colon to the rectal stump. Due to the small size of
it and the otherwise healthy
appearance of the anastomosis, decision was made to repair
it and do a diverting
ileostomy. The area was oversewn using several interrupted
3-0 Vicryl sutures in an
imbricating fashion to include portion of the rectum an
d then the colon walls. The pelvis
and abdomen was then copiously irrigated and suctioned dry
A flat Jackson-Pratt drain
was then placed through a stab incision in the right
lower quadrant. A position just
above the iliac crest was then chosen for creation of a
diverting ileostomy, and a small
circular portion of skin was removed after grasping the ski
n with an Allis clamp with
electrocautery. A small cruciate incision was then made wit
h the cautery in the overlying
fascia. The rectus muscle was split, and the posterior fascia
and peritoneum was then
divided again using electrocautery. The distal ileum in
a loop fashion was then brought
up through the skin opening and a small rent was made i
n the mesentery and a diverting
rod was placed through it to hold it above the skin.
Attention was then turned to the
abdomen. Sponge count, instrument count, and needle
count was taken and found to
be correct. The nasogastric tube was again checked for appropriate
positioning. The
fascia was then reapproximated using interrupted figure-
of-eight #1 Vicryl sutures. The
wound was irrigated again and a 1/4-inch Penrose drain
was placed in the subcutaneous
tissues, and the skin was reapproximated using skin staples.
The Jackson-Pratt drain
was transfixed to the skin using 3-0 Prolene suture as we
re the Penrose drains at either
end of the incision. The ileostomy was then matured.
Thank you in advance for any assistance
PROCEDURE:
An orogastric tube was initially placed and then, due to
the volume of fluid in her
stomach, converted to a nasogastric tube and eventually
1,300 mL of fluid was removed
through the nasogastric tube. The gross findings are as
described above. After sterilely
prepping and draping the patient in the usual fashion
and a surgical time out was held,
the staples were removed from her original incision in
the left lower quadrant and then
the fascial sutures were transected with Mayo scissors; and
the peritoneal cavity was
then entered with the gross findings as described above.
A self-retaining Balfour
retractor was then placed. Again the gross findings as
described above. Upon noting
where the mostly bilious material was noted in the right
pelvis, the small bowel was run
completely with no evidence of any small bowel rupture or
injury. Eventually it was
noted that the collection was coming from the right
lateral aspect of the anastomosis of
the colon to the rectal stump. Due to the small size of
it and the otherwise healthy
appearance of the anastomosis, decision was made to repair
it and do a diverting
ileostomy. The area was oversewn using several interrupted
3-0 Vicryl sutures in an
imbricating fashion to include portion of the rectum an
d then the colon walls. The pelvis
and abdomen was then copiously irrigated and suctioned dry
A flat Jackson-Pratt drain
was then placed through a stab incision in the right
lower quadrant. A position just
above the iliac crest was then chosen for creation of a
diverting ileostomy, and a small
circular portion of skin was removed after grasping the ski
n with an Allis clamp with
electrocautery. A small cruciate incision was then made wit
h the cautery in the overlying
fascia. The rectus muscle was split, and the posterior fascia
and peritoneum was then
divided again using electrocautery. The distal ileum in
a loop fashion was then brought
up through the skin opening and a small rent was made i
n the mesentery and a diverting
rod was placed through it to hold it above the skin.
Attention was then turned to the
abdomen. Sponge count, instrument count, and needle
count was taken and found to
be correct. The nasogastric tube was again checked for appropriate
positioning. The
fascia was then reapproximated using interrupted figure-
of-eight #1 Vicryl sutures. The
wound was irrigated again and a 1/4-inch Penrose drain
was placed in the subcutaneous
tissues, and the skin was reapproximated using skin staples.
The Jackson-Pratt drain
was transfixed to the skin using 3-0 Prolene suture as we
re the Penrose drains at either
end of the incision. The ileostomy was then matured.