mfournier
Networker
Hello Everyone:
Was wondering if someone can shade some light on this surgical case. I was thinking the 44188 but not sure what to do about the fistula. There is an old post that recommend 44144-52. But that was posted quite a few years back. Listed is the op note. Thanks for any clarification.
Procedure: Laparoscopic assisted diverting sigmoid colostomy with mucous fistula
Procedural technique: After obtaining adequate informed consent the patient was taken the operating theater. After induction of general tracheal anesthesia, patient was positioned in supine position with arms placed tucked and padded against the sides. Foley catheter was placed in aseptic manner with return of clear yellow urine by the nursing staff. During Foley catheter placement, tumor was visualized to be invading the perineal body, posterior fourchette of the vagina with a leading edge of the tumor encroaching upon the labia majora, extending down to the ischial anal fossa on the left side as previously noted at prior exam under anesthesia. Once Foley catheter was in place, the patient abdomen slightly prepped and draped in standard sterile surgical fashion. Surgical timeout was conducted per the institutional protocol, supportive satisfied would like to proceed. We began the left lower quadrant at the marked ostomy site excising the skin disc. We dissected down through subcutaneous tissues to the rectus fascia was encountered and incised in a cruciate manner. Rectus muscle belly was divided bluntly until we encountered the posterior fascia which was incised vertically electrocautery after initial entry into the abdominal cavity in a controlled manner using Metzenbaum scissor. The ostomy aperture was developed and the extra small Alexis wound retractor was positioned to retract the abdominal wall. The sigmoid colon was not immediately visualized. A 10 mm trocar was introduced through the port, a Penrose drain was used to occlude the wound protector around this to produce a pneumoperitoneum with CO2 gas. The 5 mm 30 degree camera was inserted through the 10 mm port I placed 2 5 mm ports 1 in the right midclavicular line in the right upper quadrant 1 in the right lower quadrant lateral to inferior epigastric vessels. Patient was then rotated to a left left side up position, the white line of Toldt was identified to the left pelvic brim and widely mobilized from the left pelvic brim to the distal aspect of the splenic flexure mobilizing the sigmoid colon and the descending colon nicely and essentially making these midline structures and easily mobile to the abdominal wall. This was done with the LigaSure. Once mobilization was complete, a Babcock clamp was placed across the distal sigmoid colon and the distal sigmoid colon was delivered through the abdominal wall at the 10 mm port site after the 5 mm ports were backed up flush to the abdominal wall, and the pneumoperitoneum was decompressed by removing the 10 mm port at the Alexis wound retractor. Sigmoid colon was delivered through the abdominal wall here, the mesentery was cleared away from the colon here in the mesenteric marginal vessel divided with the LigaSure. A 75 mm GIA stapler with a blue load was directed across the colon, used to divide the colon here. The perceived downstream and which I intended to mature as a mucous fistula was marked with a single 3-0 Vicryl suture. The colon was then returned to the abdominal cavity. I now visually ran the colon both proximally and distally confirming that the 3-0 Vicryl suture was in fact on the distal staple line. Confirming this now as the distal tissue we returned the colon to its position of exteriorization with Allis clamps placed on the upstream and at either corner, and a single Allis clamp placed in the mid portion of the distal staple line. The 5 mm ports were removed under visualization, no bleeding noted at the port sites. The pneumoperitoneum was released. 5 mm ports repaired with 4-0 Monocryl in a subcuticular manner and Dermabond skin sealant. We now turned our attention to removal of the Alexis wound retractor. The lateral one third of the distal end of the colon was opened along the staple line, and this was matured as a mucous fistula along the inferior aspect of the ostomy from approximately 5:00 to 7:00. The upstream colon was then opened along the entire staple line, and matured in a modified Brooke manner with 1 cm V version with the distal edge secured to the upstream edge of the mucous fistula inferiorly with interrupted 0 Vicryl suture. The mucous fistula would just admit the fifth digit and was patent to this inspection to the level of the fascia. Similarly the upstream and once matured was patent widely. Ostomy appliance was cut to fit and put in place. Procedure was now complete, anesthesia reversed, the patient was extubated, and taken the postanesthesia care in stable condition having tolerated the procedure well no apparent complication. Was present scrubbed for the entire case as detailed. Again all sponge instrument sharp counts reported as correct
Thank you for any clarification
Was wondering if someone can shade some light on this surgical case. I was thinking the 44188 but not sure what to do about the fistula. There is an old post that recommend 44144-52. But that was posted quite a few years back. Listed is the op note. Thanks for any clarification.
Procedure: Laparoscopic assisted diverting sigmoid colostomy with mucous fistula
Procedural technique: After obtaining adequate informed consent the patient was taken the operating theater. After induction of general tracheal anesthesia, patient was positioned in supine position with arms placed tucked and padded against the sides. Foley catheter was placed in aseptic manner with return of clear yellow urine by the nursing staff. During Foley catheter placement, tumor was visualized to be invading the perineal body, posterior fourchette of the vagina with a leading edge of the tumor encroaching upon the labia majora, extending down to the ischial anal fossa on the left side as previously noted at prior exam under anesthesia. Once Foley catheter was in place, the patient abdomen slightly prepped and draped in standard sterile surgical fashion. Surgical timeout was conducted per the institutional protocol, supportive satisfied would like to proceed. We began the left lower quadrant at the marked ostomy site excising the skin disc. We dissected down through subcutaneous tissues to the rectus fascia was encountered and incised in a cruciate manner. Rectus muscle belly was divided bluntly until we encountered the posterior fascia which was incised vertically electrocautery after initial entry into the abdominal cavity in a controlled manner using Metzenbaum scissor. The ostomy aperture was developed and the extra small Alexis wound retractor was positioned to retract the abdominal wall. The sigmoid colon was not immediately visualized. A 10 mm trocar was introduced through the port, a Penrose drain was used to occlude the wound protector around this to produce a pneumoperitoneum with CO2 gas. The 5 mm 30 degree camera was inserted through the 10 mm port I placed 2 5 mm ports 1 in the right midclavicular line in the right upper quadrant 1 in the right lower quadrant lateral to inferior epigastric vessels. Patient was then rotated to a left left side up position, the white line of Toldt was identified to the left pelvic brim and widely mobilized from the left pelvic brim to the distal aspect of the splenic flexure mobilizing the sigmoid colon and the descending colon nicely and essentially making these midline structures and easily mobile to the abdominal wall. This was done with the LigaSure. Once mobilization was complete, a Babcock clamp was placed across the distal sigmoid colon and the distal sigmoid colon was delivered through the abdominal wall at the 10 mm port site after the 5 mm ports were backed up flush to the abdominal wall, and the pneumoperitoneum was decompressed by removing the 10 mm port at the Alexis wound retractor. Sigmoid colon was delivered through the abdominal wall here, the mesentery was cleared away from the colon here in the mesenteric marginal vessel divided with the LigaSure. A 75 mm GIA stapler with a blue load was directed across the colon, used to divide the colon here. The perceived downstream and which I intended to mature as a mucous fistula was marked with a single 3-0 Vicryl suture. The colon was then returned to the abdominal cavity. I now visually ran the colon both proximally and distally confirming that the 3-0 Vicryl suture was in fact on the distal staple line. Confirming this now as the distal tissue we returned the colon to its position of exteriorization with Allis clamps placed on the upstream and at either corner, and a single Allis clamp placed in the mid portion of the distal staple line. The 5 mm ports were removed under visualization, no bleeding noted at the port sites. The pneumoperitoneum was released. 5 mm ports repaired with 4-0 Monocryl in a subcuticular manner and Dermabond skin sealant. We now turned our attention to removal of the Alexis wound retractor. The lateral one third of the distal end of the colon was opened along the staple line, and this was matured as a mucous fistula along the inferior aspect of the ostomy from approximately 5:00 to 7:00. The upstream colon was then opened along the entire staple line, and matured in a modified Brooke manner with 1 cm V version with the distal edge secured to the upstream edge of the mucous fistula inferiorly with interrupted 0 Vicryl suture. The mucous fistula would just admit the fifth digit and was patent to this inspection to the level of the fascia. Similarly the upstream and once matured was patent widely. Ostomy appliance was cut to fit and put in place. Procedure was now complete, anesthesia reversed, the patient was extubated, and taken the postanesthesia care in stable condition having tolerated the procedure well no apparent complication. Was present scrubbed for the entire case as detailed. Again all sponge instrument sharp counts reported as correct
Thank you for any clarification
