Assistance requested
With over 15 years of coding, I feel defeated to ask for help, but this case has left me overwhelmed! Any help is much appreciated with CPT suggestions
Thank you in advance, Shelly
After informed consent was obtained, the patient was taken to the operating room and placed in the supine position. After adequate endotracheal anesthesia was achieved, the patient was switched to lithotomy position and the colostomy was sewn shut and the rectum washed out with Betadine. The abdomen perineum were then all prepped and draped in a sterile fashion. Operation was begun by placing an 8 mm periumbilical incision with which an 8 mm trocar was introduced into the abdomen using Optiview technique. After pneumoperitoneum is achieved, additional trochars were placed 2 more 8 mm trochars and a 12 mm robotic port in the right lower quadrant as well as a 5 mm assist port. All trochars were placed absent Marcaine with epinephrine for local anesthesia. We made a circular incision in the left lower quadrant around the loop colostomy site and separated these from the surrounding subcu and skin attachments and peritoneal attachments as well. We then divided the bowel through mesenteric windows proximally and distally and divided the mesentery in between with clamps and 0 Vicryl ties. This was removed and sent as specimen #1. We then placed an Alexis wound retractor into the wound and clamped this off and pneumoperitoneum was achieved.
After positioning the patient and docking the da Vinci X Xi robotic system, we began by taking down the lateral attachments of the sigmoid colon. Dissecting into the retroperitoneum, we identified the ureter and gonadal vessels and preserve these throughout the case. We then open the peritoneum on the right medial side of the rectum and connected to our previous dissection plane. After reflecting the pelvic nerves downward we isolated the IMA pedicle and ligated this with a vessel sealer device with resulting hemostasis. We then divided the mesentery up to the point between the already divided colon and the previous loop colostomy with hemostasis.
We then turned our attention toward the pelvic floor and began dissecting in the presacral bloodless plane. We took down left and right lateral attachments ligated branches of the middle rectal arteries. We open the anterior retroperitoneum and separated did not BAs fascia from the mesorectum as well. Continuing our dissection toward the pelvic floor, we eventually were able to free up all of the attachments of the mesorectum. Next we cut through the pelvic floor muscles around the posterior and lateral sides at which point we felt that the abdominal portion of the dissection was completed and would continue the dissection from the perineal approach.
We placed a 19 French round drain and deep into the pelvis through one of the trocar sites. We then closed the fascia at the 12 m trocar site using a 0 PDS with an Endo Close device. Pneumoperitoneum was reduced and all trochars removed. Skin incisions were closed with clean gloves and instruments using 4-0 Monocryl and Dermabond. The drain was sewn to the skin with a 2-0 nylon and hooked to bulb suction at the end of the case. We brought the end of the colon out through the former colostomy site and then matured this to the skin as an end colostomy using 3-0 Vicryl sutures with a Brooke technique. Ostomy appliance was placed.
Next we turned our attention toward the perineal approach. After shaving here off the skin we made a circular incision around the anus just outside the sphincter muscles. We then secured a Lone Star retractor into place and continued our dissection with cautery and LigaSure device removing the entire sphincter complex en bloc with the anal canal. Our dissection continued through the anal coccygeal ligament until we are able to break into the previous dissection plane from the abdominal approach. We then used LigaSure to continue removing pelvic floor attachments 360 degrees around the residual anal canal using her previous dissection plane as a guidance. We then extracted the entire surgical specimen through the perineal wounds and irrigated with warm saline.
We now repaired the pelvic floor using a biologic mesh. A piece of Zen matrix was cut into a U-shaped and then sewn to the posterior and lateral pelvic floor the mesh shape held in place anteriorly without risking injury to the prostate. With the pelvic floor thus closed we inserted a 10 French round drain into the subcu space created. We then sewed this to the skin with a silk and opted to bulb suction the end of the case. We closed the skin wound with a 0 silk vertical mattress sutures and placed Neosporin ointment and dry sterile gauze. The procedure was then concluded and the patient returned to the PACU in stable condition. All instrument counts were correct at the end of the procedure.
With over 15 years of coding, I feel defeated to ask for help, but this case has left me overwhelmed! Any help is much appreciated with CPT suggestions Thank you in advance, ShellyAfter informed consent was obtained, the patient was taken to the operating room and placed in the supine position. After adequate endotracheal anesthesia was achieved, the patient was switched to lithotomy position and the colostomy was sewn shut and the rectum washed out with Betadine. The abdomen perineum were then all prepped and draped in a sterile fashion. Operation was begun by placing an 8 mm periumbilical incision with which an 8 mm trocar was introduced into the abdomen using Optiview technique. After pneumoperitoneum is achieved, additional trochars were placed 2 more 8 mm trochars and a 12 mm robotic port in the right lower quadrant as well as a 5 mm assist port. All trochars were placed absent Marcaine with epinephrine for local anesthesia. We made a circular incision in the left lower quadrant around the loop colostomy site and separated these from the surrounding subcu and skin attachments and peritoneal attachments as well. We then divided the bowel through mesenteric windows proximally and distally and divided the mesentery in between with clamps and 0 Vicryl ties. This was removed and sent as specimen #1. We then placed an Alexis wound retractor into the wound and clamped this off and pneumoperitoneum was achieved.
After positioning the patient and docking the da Vinci X Xi robotic system, we began by taking down the lateral attachments of the sigmoid colon. Dissecting into the retroperitoneum, we identified the ureter and gonadal vessels and preserve these throughout the case. We then open the peritoneum on the right medial side of the rectum and connected to our previous dissection plane. After reflecting the pelvic nerves downward we isolated the IMA pedicle and ligated this with a vessel sealer device with resulting hemostasis. We then divided the mesentery up to the point between the already divided colon and the previous loop colostomy with hemostasis.
We then turned our attention toward the pelvic floor and began dissecting in the presacral bloodless plane. We took down left and right lateral attachments ligated branches of the middle rectal arteries. We open the anterior retroperitoneum and separated did not BAs fascia from the mesorectum as well. Continuing our dissection toward the pelvic floor, we eventually were able to free up all of the attachments of the mesorectum. Next we cut through the pelvic floor muscles around the posterior and lateral sides at which point we felt that the abdominal portion of the dissection was completed and would continue the dissection from the perineal approach.
We placed a 19 French round drain and deep into the pelvis through one of the trocar sites. We then closed the fascia at the 12 m trocar site using a 0 PDS with an Endo Close device. Pneumoperitoneum was reduced and all trochars removed. Skin incisions were closed with clean gloves and instruments using 4-0 Monocryl and Dermabond. The drain was sewn to the skin with a 2-0 nylon and hooked to bulb suction at the end of the case. We brought the end of the colon out through the former colostomy site and then matured this to the skin as an end colostomy using 3-0 Vicryl sutures with a Brooke technique. Ostomy appliance was placed.
Next we turned our attention toward the perineal approach. After shaving here off the skin we made a circular incision around the anus just outside the sphincter muscles. We then secured a Lone Star retractor into place and continued our dissection with cautery and LigaSure device removing the entire sphincter complex en bloc with the anal canal. Our dissection continued through the anal coccygeal ligament until we are able to break into the previous dissection plane from the abdominal approach. We then used LigaSure to continue removing pelvic floor attachments 360 degrees around the residual anal canal using her previous dissection plane as a guidance. We then extracted the entire surgical specimen through the perineal wounds and irrigated with warm saline.
We now repaired the pelvic floor using a biologic mesh. A piece of Zen matrix was cut into a U-shaped and then sewn to the posterior and lateral pelvic floor the mesh shape held in place anteriorly without risking injury to the prostate. With the pelvic floor thus closed we inserted a 10 French round drain into the subcu space created. We then sewed this to the skin with a silk and opted to bulb suction the end of the case. We closed the skin wound with a 0 silk vertical mattress sutures and placed Neosporin ointment and dry sterile gauze. The procedure was then concluded and the patient returned to the PACU in stable condition. All instrument counts were correct at the end of the procedure.
