l1ttle_0ne
Guru
I'm not sure if the coding on this surgery is correct. the codes that I came up with are 44207, 44213, 44187. Any opinions?? Your help is greatly appreciated. I don't have a lot of experience with these surgeries. Thank you for your help!!
PREOP DX: Malignant neoplasm of colon, unspecified site [153.9]
POSTOP DX: rectal cancer (upper 1/3 rectum)
SURGEON:
OPERATIVE PROCEDURE:
Laparoscopic low anterior resection with coloproctostomy
Laparoscopic splenic flexure mobilization
3 Diverting ileostomy
FINDINGS: Liver with cirrhosis noted. The tumor was in the upper third of the rectum, at the peritoneal reflection. It had started to erode through the wall of the anterior rectum (i.e. T4 likely). The rectum and the distal sigmoid colon was resected. A stapled, 29 mm end to end anastomosis created between the proximal sigmoid colon and the rectum that was tension free, had excellent blood supply, and full tissue apposition. Air leak test revealed no leak. Given the cirrhosis, the bulky tumor, and general difficulty of the case a diverting ileostomy was created. I broke scrub and discussed ileostomy with the family.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and given general anesthetic. Patient sterilely prepped and draped in the low lithotomy position. A Pfannenstiel incision was created. This was followed by a 12 mm supraumbilical port and a 5 mm left lower quadrant port. A 12 mm RLQ port was placed.
The sigmoid colon was mobilized from the pelvic brim using electrocautery at the beginning of the procedure. Following this, laparoscopically the sigmoid colon and descending colon were mobilized from the retroperitoneum. The splenic flexure was mobilized by dividing the splenocolic ligament. The remaining retroperitoneal attachments were freed as well. The superior hemorrhoidal artery was then identified and divided with clips and then tied with an 0 vicryl tie. The colon was transected at the mid-sigmoid colon junction and a 29 mm anvil head was sewn in place with a 2-0 prolene pursestring suture.
Following this, the peritoneal reflections were scored. The presacral space was entered, talking care to preserve the superior hypogastric nerve plexus. The lateral stalks were scored. Dissection carried anterior, seperating the rectum from the prostate. The rectum was divided from the underlying mesorectum using the Harmonic scalpel and electrocautery. The rectum was transected with a purple load Covidien curved linear cutter. A 29 mm end-to-end anastomosis was created. This was visualised with a rigid sigmoidoscope and tested with air and no leak was noted.
Nuknit gauze placed at the splenic flexure and the left retrocolic gutter. Floseal placed here as well.
Antibiotic irrigation placed in pelvis for three minutes. Floseal placed in the pelvis. RLQ circular incision made and the terminal ileum brought into the incision. The Pfannenstiel incision was closed with running PDS sutures. Skin was closed with subcuticular sutures followed with glue on skin. Ileostomy matured with chromic sutures (sepra film placed as well). No complications.
EBL: 500 ml
SPECIMENS:
Proximal rectum
COMPLICATIONS: None.
PREOP DX: Malignant neoplasm of colon, unspecified site [153.9]
POSTOP DX: rectal cancer (upper 1/3 rectum)
SURGEON:
OPERATIVE PROCEDURE:
Laparoscopic low anterior resection with coloproctostomy
Laparoscopic splenic flexure mobilization
3 Diverting ileostomy
FINDINGS: Liver with cirrhosis noted. The tumor was in the upper third of the rectum, at the peritoneal reflection. It had started to erode through the wall of the anterior rectum (i.e. T4 likely). The rectum and the distal sigmoid colon was resected. A stapled, 29 mm end to end anastomosis created between the proximal sigmoid colon and the rectum that was tension free, had excellent blood supply, and full tissue apposition. Air leak test revealed no leak. Given the cirrhosis, the bulky tumor, and general difficulty of the case a diverting ileostomy was created. I broke scrub and discussed ileostomy with the family.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and given general anesthetic. Patient sterilely prepped and draped in the low lithotomy position. A Pfannenstiel incision was created. This was followed by a 12 mm supraumbilical port and a 5 mm left lower quadrant port. A 12 mm RLQ port was placed.
The sigmoid colon was mobilized from the pelvic brim using electrocautery at the beginning of the procedure. Following this, laparoscopically the sigmoid colon and descending colon were mobilized from the retroperitoneum. The splenic flexure was mobilized by dividing the splenocolic ligament. The remaining retroperitoneal attachments were freed as well. The superior hemorrhoidal artery was then identified and divided with clips and then tied with an 0 vicryl tie. The colon was transected at the mid-sigmoid colon junction and a 29 mm anvil head was sewn in place with a 2-0 prolene pursestring suture.
Following this, the peritoneal reflections were scored. The presacral space was entered, talking care to preserve the superior hypogastric nerve plexus. The lateral stalks were scored. Dissection carried anterior, seperating the rectum from the prostate. The rectum was divided from the underlying mesorectum using the Harmonic scalpel and electrocautery. The rectum was transected with a purple load Covidien curved linear cutter. A 29 mm end-to-end anastomosis was created. This was visualised with a rigid sigmoidoscope and tested with air and no leak was noted.
Nuknit gauze placed at the splenic flexure and the left retrocolic gutter. Floseal placed here as well.
Antibiotic irrigation placed in pelvis for three minutes. Floseal placed in the pelvis. RLQ circular incision made and the terminal ileum brought into the incision. The Pfannenstiel incision was closed with running PDS sutures. Skin was closed with subcuticular sutures followed with glue on skin. Ileostomy matured with chromic sutures (sepra film placed as well). No complications.
EBL: 500 ml
SPECIMENS:
Proximal rectum
COMPLICATIONS: None.