maine4me
Guru
I have read and read this operative note and am unsure how to code it. If I
am following the sequence of events, the procedure started as laparoscopic
and because of a peristomal hernia encounter during the procedure, the
laparoscopic portion was stopped to take down the colostomy, and then
resumed laparoscopically for the takedown of the spenic flexure of the
colong. How is this coded??
PREOPERATIVE DIAGNOSIS: Status post perforated diverticulitis with
Hartmann procedure
and temporary colostomy
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Laparoscopic closure of colostomy with resection of portion
descending colon
and takedown of splenic flexure of colon
ANESTHESIA: General
PROCEDURE AND FINDINGS: The patient was brought to the Operating Room,
properly
identified, placed on the table in the supine position.
Preop diagnosis, procedure, and site were confirmed on time out. He had
Ancef, Flagyl
preop. He had induction of general anesthesia. He then had cystoscopy with
insertion of
lighted ureteral stents, as per Dr. X's note.
The patient then remained in lithotomy position and the colostomy was first
closed by
simply doing a pursestring of heavy suture around the mucosa to avoid any
potential
leakage. The abdomen was then washed with Betadine scrub and then Betadine
solution to
the abdomen and perineum. Drapes were applied.
A small incision made above the umbilicus and the Veress needle used to
insufflate the
abdomen to 14 mmHg. A 5 mm Optiview trocar with the laparoscope was used
to enter the
abdomen under direct vision. In addition, a 5 mm right upper quadrant and a
12 mm right
lower quadrant trocars were inserted through small incisions under direct
vision of the
laparoscope.
There were some minor adhesions lysed. There was noted to be peristomal
hernia and a good
deal of what appeared to be mesentery adhered to the anterior abdominal
wall. Because of
this, it was then elected to take down the colostomy by stopping the
laparoscopic portion
of the surgery and doing an elliptical incision around the colostomy and
carrying this
down through subcutaneous tissue and then freeing the colostomy totally
from the fascia.
Once it was freed, there was enough length to be able to pull the colon up
through the
incision and mesentery was divided approximately 8 cm from the end, and the
bowel
appeared in good shape at this point and a pursestring suture was placed
and the anvil of
an EEA 29 stapler was placed into the lumen and the pursestring was tied
down and the
bowel was encircled again with the same nylon suture and tied. The colon
was then dropped
back inside the abdomen and the peritoneum and posterior fascia was closed
with running
#1 PDS and then the anterior fascia was closed with a running #1 PDS.
Saline gauze was applied. The abdomen was then re insufflated and the
laparoscopic
portion proceeded. The Prolene sutures left on the rectal stump were
identified and the
rectal stump was very adherent to the sacrum. The descending colon was
taken into the
pelvis and it was felt that there was not enough length and therefore the
Harmonic
scalpel was further used to free the left colon from the gutter and up
around the splenic
flexure entirely to allow the splenic flexure of the colon to be retracted
inferiorly.
Once this was totally accomplished it was felt that the bowel had enough
length. The
assistant then went to the perineum and dilated the anus, and placed the
dilators up
through the anus into the rectum and finally the stapler was placed, the
trocar advanced,
and the stapler locked in place, closed, and fired. The stapler was removed
and the 2
donuts were intact. Air was then insufflated with the Foley catheter and
with the
anastomosis under saline no air leakage was noted. There did not appear to
be any undue
tension on the anastomosis.
The abdomen was then irrigated further with saline and suctioned dry. A
flat J-Vac was
placed through the larger trocar and brought out through the upper one and
a Ranfac type
needle was used to close the fascia with an 0 Vicryl at the 12 mm port
site. Gas was
evacuated from the last trocar and it was removed. The drain was sutured to
the skin with
nylon. The colostomy site was irrigated thoroughly and deeper subcutaneous
closed with 0
Vicryl and the more superficial subcutaneous closed with 2-0 Vicryl and
then the skin
closed with proximate clips to this site and to the trocar sites. Dressings
were applied.
Needle, sponge, and instrument count was correct x 2 and blood loss was
minimal. The patient left the Operating Room in stable condition, breathing
on his own, to recover
in the PACU.
am following the sequence of events, the procedure started as laparoscopic
and because of a peristomal hernia encounter during the procedure, the
laparoscopic portion was stopped to take down the colostomy, and then
resumed laparoscopically for the takedown of the spenic flexure of the
colong. How is this coded??
PREOPERATIVE DIAGNOSIS: Status post perforated diverticulitis with
Hartmann procedure
and temporary colostomy
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Laparoscopic closure of colostomy with resection of portion
descending colon
and takedown of splenic flexure of colon
ANESTHESIA: General
PROCEDURE AND FINDINGS: The patient was brought to the Operating Room,
properly
identified, placed on the table in the supine position.
Preop diagnosis, procedure, and site were confirmed on time out. He had
Ancef, Flagyl
preop. He had induction of general anesthesia. He then had cystoscopy with
insertion of
lighted ureteral stents, as per Dr. X's note.
The patient then remained in lithotomy position and the colostomy was first
closed by
simply doing a pursestring of heavy suture around the mucosa to avoid any
potential
leakage. The abdomen was then washed with Betadine scrub and then Betadine
solution to
the abdomen and perineum. Drapes were applied.
A small incision made above the umbilicus and the Veress needle used to
insufflate the
abdomen to 14 mmHg. A 5 mm Optiview trocar with the laparoscope was used
to enter the
abdomen under direct vision. In addition, a 5 mm right upper quadrant and a
12 mm right
lower quadrant trocars were inserted through small incisions under direct
vision of the
laparoscope.
There were some minor adhesions lysed. There was noted to be peristomal
hernia and a good
deal of what appeared to be mesentery adhered to the anterior abdominal
wall. Because of
this, it was then elected to take down the colostomy by stopping the
laparoscopic portion
of the surgery and doing an elliptical incision around the colostomy and
carrying this
down through subcutaneous tissue and then freeing the colostomy totally
from the fascia.
Once it was freed, there was enough length to be able to pull the colon up
through the
incision and mesentery was divided approximately 8 cm from the end, and the
bowel
appeared in good shape at this point and a pursestring suture was placed
and the anvil of
an EEA 29 stapler was placed into the lumen and the pursestring was tied
down and the
bowel was encircled again with the same nylon suture and tied. The colon
was then dropped
back inside the abdomen and the peritoneum and posterior fascia was closed
with running
#1 PDS and then the anterior fascia was closed with a running #1 PDS.
Saline gauze was applied. The abdomen was then re insufflated and the
laparoscopic
portion proceeded. The Prolene sutures left on the rectal stump were
identified and the
rectal stump was very adherent to the sacrum. The descending colon was
taken into the
pelvis and it was felt that there was not enough length and therefore the
Harmonic
scalpel was further used to free the left colon from the gutter and up
around the splenic
flexure entirely to allow the splenic flexure of the colon to be retracted
inferiorly.
Once this was totally accomplished it was felt that the bowel had enough
length. The
assistant then went to the perineum and dilated the anus, and placed the
dilators up
through the anus into the rectum and finally the stapler was placed, the
trocar advanced,
and the stapler locked in place, closed, and fired. The stapler was removed
and the 2
donuts were intact. Air was then insufflated with the Foley catheter and
with the
anastomosis under saline no air leakage was noted. There did not appear to
be any undue
tension on the anastomosis.
The abdomen was then irrigated further with saline and suctioned dry. A
flat J-Vac was
placed through the larger trocar and brought out through the upper one and
a Ranfac type
needle was used to close the fascia with an 0 Vicryl at the 12 mm port
site. Gas was
evacuated from the last trocar and it was removed. The drain was sutured to
the skin with
nylon. The colostomy site was irrigated thoroughly and deeper subcutaneous
closed with 0
Vicryl and the more superficial subcutaneous closed with 2-0 Vicryl and
then the skin
closed with proximate clips to this site and to the trocar sites. Dressings
were applied.
Needle, sponge, and instrument count was correct x 2 and blood loss was
minimal. The patient left the Operating Room in stable condition, breathing
on his own, to recover
in the PACU.