CCANTER
Networker
I was just needing help with whether to code this as an open or laparoscopic procedure? The way i read this is the surgeon performed first a laparoscopy and then performed an open hemicolectomy. But now I am questioning myself
Patient was placed with arms out and a small bump under patient's knees and patient's legs taped and belted in place with foot rests. Tje abdomen was then prepped and draped in the usual sterile fashion. A timeout was taken to confirm the correct patient, position, procedure.
A 7 cm midline incision was made. This was taken down to the level of the fascia bluntly and with electrocautery. The fascia was elevated between 2 Kocher's and the abdomen carefully entered with Metzenbaum scissors. A finger was inserted and the remaining fascia was opened with electrocautery. A wound retractor for the GelPort was placed. Three 5 mm working ports were placed, 1 in the epigastrium, 1 in the left upper abdomen, and a third was placed in the low midline. The abdomen was insufflated and the camera inserted. A careful inspection visually and with palpation of the abdomen was performed and there was no obvious metastatic disease. The ascending colon mass was easily palpated. The tattoo was visible. The mass was mobile. The decision was made to proceed with right hemicolectomy with side-to-side ileocolostomy.
Patient was placed in a reverse Trendelenburg position. We began with a medial approach and identified the ileocolic pedicle by elevating the cecum. Using a LigaSure device, a parallel incision was made in the mesentery adjacent to the vessels. The pulse was palpable. A second incision was made lateral to the vessels and they were skeletonized. The duodenum was visualized and protected. The vein and artery were individually doubly clipped proximally and single clips placed distally and divided with the energy device. The dissection continued from a medial to lateral approach continuing over the duodenum and then Gerota's fascia to the sidewall and continuing superiorly to the hepatic flexure and inferiorly to the cecum.
Also in a Trendelenburg position and the splenic flexure was mobilized by taking down the hepatocolic ligament and then continuing this inferiorly along the white line freeing up the colon.
The GelPort was taken out leaving the wound protector in place. The proximal point of transection was identified about 8 cm proximal to the ileocecal valve and the bowel was divided with a GIA stapler. The remaining mesentery was divided with the LigaSure. The distal point of transection was then identified and again the bowel was divided with a GIA stapler. The remaining attachments were divided with the LigaSure device and the specimen was removed from the abdomen.
The terminal ileum was able to reach the transverse colon without any tension. A 3-0 Vicryl was used to close the internal hernia starting laterally over Gerota's fascia up to the anastomosis. The side to side anastomosis was then created between the terminal ileum and the transverse colon with a 75 mm GIA stapler. The common defect was closed with a TX 60 mm stapler and a silk stitch was placed to reinforce the staple line of the anastomosis. 3-0 Vicryl's were used to imbricate the staple line of the 60 mm stapler.
The abdomen was irrigated with a couple of liters of warm saline. The omentum was brought down deep to the midline incision and the fascia was closed in a running fashion with 0 PDS. Marcaine was infiltrated into the fascia. 2-0 Vicryl was used in a running fashion to close Scarpa's. 3-0 Vicryl was used to reapproximate the dermis in an interrupted fashion. The skin was closed with a running subcuticular 4-0 Monocryl. A glue dressing was applied to all incisions.
Patient was placed with arms out and a small bump under patient's knees and patient's legs taped and belted in place with foot rests. Tje abdomen was then prepped and draped in the usual sterile fashion. A timeout was taken to confirm the correct patient, position, procedure.
A 7 cm midline incision was made. This was taken down to the level of the fascia bluntly and with electrocautery. The fascia was elevated between 2 Kocher's and the abdomen carefully entered with Metzenbaum scissors. A finger was inserted and the remaining fascia was opened with electrocautery. A wound retractor for the GelPort was placed. Three 5 mm working ports were placed, 1 in the epigastrium, 1 in the left upper abdomen, and a third was placed in the low midline. The abdomen was insufflated and the camera inserted. A careful inspection visually and with palpation of the abdomen was performed and there was no obvious metastatic disease. The ascending colon mass was easily palpated. The tattoo was visible. The mass was mobile. The decision was made to proceed with right hemicolectomy with side-to-side ileocolostomy.
Patient was placed in a reverse Trendelenburg position. We began with a medial approach and identified the ileocolic pedicle by elevating the cecum. Using a LigaSure device, a parallel incision was made in the mesentery adjacent to the vessels. The pulse was palpable. A second incision was made lateral to the vessels and they were skeletonized. The duodenum was visualized and protected. The vein and artery were individually doubly clipped proximally and single clips placed distally and divided with the energy device. The dissection continued from a medial to lateral approach continuing over the duodenum and then Gerota's fascia to the sidewall and continuing superiorly to the hepatic flexure and inferiorly to the cecum.
Also in a Trendelenburg position and the splenic flexure was mobilized by taking down the hepatocolic ligament and then continuing this inferiorly along the white line freeing up the colon.
The GelPort was taken out leaving the wound protector in place. The proximal point of transection was identified about 8 cm proximal to the ileocecal valve and the bowel was divided with a GIA stapler. The remaining mesentery was divided with the LigaSure. The distal point of transection was then identified and again the bowel was divided with a GIA stapler. The remaining attachments were divided with the LigaSure device and the specimen was removed from the abdomen.
The terminal ileum was able to reach the transverse colon without any tension. A 3-0 Vicryl was used to close the internal hernia starting laterally over Gerota's fascia up to the anastomosis. The side to side anastomosis was then created between the terminal ileum and the transverse colon with a 75 mm GIA stapler. The common defect was closed with a TX 60 mm stapler and a silk stitch was placed to reinforce the staple line of the anastomosis. 3-0 Vicryl's were used to imbricate the staple line of the 60 mm stapler.
The abdomen was irrigated with a couple of liters of warm saline. The omentum was brought down deep to the midline incision and the fascia was closed in a running fashion with 0 PDS. Marcaine was infiltrated into the fascia. 2-0 Vicryl was used in a running fashion to close Scarpa's. 3-0 Vicryl was used to reapproximate the dermis in an interrupted fashion. The skin was closed with a running subcuticular 4-0 Monocryl. A glue dressing was applied to all incisions.