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How would this be coded? Thank you in advance for your assistance!
PREOP and POSTOPERATIVE DIAGNOSIS: Colostomy status.
PROCEDURES PERFORMED:
Exploratory laparotomy.
Extensive lysis of adhesions greater than 60 minutes.
Repair of colotomy.
Subtotal colectomy.
Colostomy take down.
Low anterior resection of pelvic anastomosis.
Rigid proctoscopy.
SURGEON: XXXXX
DRAINS: A 19-round Blake drain in the pelvis.
SPECIMENS:
Subtotal colectomy.
Rectal stump with anastomotic rings.
OPERATIVE FINDINGS: Dense intraabdominal adhesions with marked adhesions from the cecum to the undersurface of the abdominal incision and pelvis. Moderate pelvic adhesions, likely post-inflammatory. Very incredibly short transverse colon mesentery. After complete mobilization of the splenic flexure, division of the IMV insufficient length of colon was available for an anastomosis at the level required by the patient. This required dividing the middle colic vessels, and performing a rotation of the right colon on the ileal colic pedicle in order to perform a midtransverse anastomosis.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operative room and underwent induction of general anesthesia. He was placed on low-modified lithotomy position with all pressure points well padded. His abdomen and pelvis were prepped and draped in standard sterile surgical fashion. The patient's prior laparotomy was carefully reopened, and I actually entered the abdomen just below the area of the patient's laparotomy. However, dense adhesions in this area resulted in a small colotomy in the cecum, which was inherent to the procedure given the patient's dense adhesions. After complete opening of the incision and mobilization of the pelvic structures, I was able to repair this in 2 layers using running #1 3-0 Vicryl and then interrupted 3-0 Vicryl Lemberted sutures to complete the repair of this area. Extensive lysis of adhesions was performed over greater than 60 minutes. I first started in the pelvis freeing up the rectum and entering the presacral space and mobilizing the rectum posteriorly. Corresponding lateral dissections were performed on either side, and I freed up the significant adhesions to the rectum in order to pass a dilator. I originally passed the smallest EEA Sizer and was unable to negotiate the upper part of the rectum because of inflammatory adhesions. These were taken down, after which the Sizer was easily passed through the area of adhesion. I then took down the colostomy and completely mobilized the splenic flexure in lateral to medial fashion and divided the IMV at its origin. After these maneuvers, insufficient length was available from the colon to reach the area of the planned anastomosis. The patient's transverse mesentery was incredibly short and tethered the entire transverse colon. I then sacrificed taking the middle colic vessels, which resulted in ischemia of the distal colon. I ultimately chose a margin and approximated the area of the mid transverse colon, which demonstrated excellent blood supply. A purse-string suture was then secured in the colon at this location, and the mesentery was divided, and I utilized the anvil of a 28-mm EEA stapler. The base of the mesentery was mobilized all the way up to the ileocolic vessels. A gentle rotation was performed at the right colon without occlusion of these vessels and with excellent blood supply observed in the graft as I rotated the right colon into the pelvis. The anvil of the 28-mm EEA stapler was then inserted up to the rectal apex, and the step spike was advanced and coupled with the anvil, which was then closed after ensuring no twisting or incorporation of extraneous tissue was fired. Two complete donuts were resulted. The anterior aspect of the staple line was oversewn with interrupted 3-0 Vicryl Lemberted sutures. Rigid proctoscopy demonstrated a vascularized and complete anastomosis. Underwater leak test revealed no leaking. A 19-round Blake drain was placed in the pelvis, and the anastomosis was measured at about 11 cm.
The abdomen was irrigated and found to be hemostatic, and then I placed the omentum over the underlying viscera, and closed the fascia of the ostomy site in 2 layers using #1 PDS and then the fascia at the midline using running #1 looped PDS. The subcutaneous tissues were irrigated. The skin was closed with clips.
PREOP and POSTOPERATIVE DIAGNOSIS: Colostomy status.
PROCEDURES PERFORMED:
Exploratory laparotomy.
Extensive lysis of adhesions greater than 60 minutes.
Repair of colotomy.
Subtotal colectomy.
Colostomy take down.
Low anterior resection of pelvic anastomosis.
Rigid proctoscopy.
SURGEON: XXXXX
DRAINS: A 19-round Blake drain in the pelvis.
SPECIMENS:
Subtotal colectomy.
Rectal stump with anastomotic rings.
OPERATIVE FINDINGS: Dense intraabdominal adhesions with marked adhesions from the cecum to the undersurface of the abdominal incision and pelvis. Moderate pelvic adhesions, likely post-inflammatory. Very incredibly short transverse colon mesentery. After complete mobilization of the splenic flexure, division of the IMV insufficient length of colon was available for an anastomosis at the level required by the patient. This required dividing the middle colic vessels, and performing a rotation of the right colon on the ileal colic pedicle in order to perform a midtransverse anastomosis.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operative room and underwent induction of general anesthesia. He was placed on low-modified lithotomy position with all pressure points well padded. His abdomen and pelvis were prepped and draped in standard sterile surgical fashion. The patient's prior laparotomy was carefully reopened, and I actually entered the abdomen just below the area of the patient's laparotomy. However, dense adhesions in this area resulted in a small colotomy in the cecum, which was inherent to the procedure given the patient's dense adhesions. After complete opening of the incision and mobilization of the pelvic structures, I was able to repair this in 2 layers using running #1 3-0 Vicryl and then interrupted 3-0 Vicryl Lemberted sutures to complete the repair of this area. Extensive lysis of adhesions was performed over greater than 60 minutes. I first started in the pelvis freeing up the rectum and entering the presacral space and mobilizing the rectum posteriorly. Corresponding lateral dissections were performed on either side, and I freed up the significant adhesions to the rectum in order to pass a dilator. I originally passed the smallest EEA Sizer and was unable to negotiate the upper part of the rectum because of inflammatory adhesions. These were taken down, after which the Sizer was easily passed through the area of adhesion. I then took down the colostomy and completely mobilized the splenic flexure in lateral to medial fashion and divided the IMV at its origin. After these maneuvers, insufficient length was available from the colon to reach the area of the planned anastomosis. The patient's transverse mesentery was incredibly short and tethered the entire transverse colon. I then sacrificed taking the middle colic vessels, which resulted in ischemia of the distal colon. I ultimately chose a margin and approximated the area of the mid transverse colon, which demonstrated excellent blood supply. A purse-string suture was then secured in the colon at this location, and the mesentery was divided, and I utilized the anvil of a 28-mm EEA stapler. The base of the mesentery was mobilized all the way up to the ileocolic vessels. A gentle rotation was performed at the right colon without occlusion of these vessels and with excellent blood supply observed in the graft as I rotated the right colon into the pelvis. The anvil of the 28-mm EEA stapler was then inserted up to the rectal apex, and the step spike was advanced and coupled with the anvil, which was then closed after ensuring no twisting or incorporation of extraneous tissue was fired. Two complete donuts were resulted. The anterior aspect of the staple line was oversewn with interrupted 3-0 Vicryl Lemberted sutures. Rigid proctoscopy demonstrated a vascularized and complete anastomosis. Underwater leak test revealed no leaking. A 19-round Blake drain was placed in the pelvis, and the anastomosis was measured at about 11 cm.
The abdomen was irrigated and found to be hemostatic, and then I placed the omentum over the underlying viscera, and closed the fascia of the ostomy site in 2 layers using #1 PDS and then the fascia at the midline using running #1 looped PDS. The subcutaneous tissues were irrigated. The skin was closed with clips.