codedog
True Blue
Stuck on this one , thinking 44207, not sure if i can bill the hernia , the rt sid e of colon is absent so thinking this cant be a total so looking at 44207 , please let me know what anyone thinks
PROCEDURE PERFORMED: Laparoscopic subtotal colectomy with ileorectal
anastomosis and incisional hernia repair..
POSTOPERATIVE DIAGNOSIS: Colon adenoma.
.
TECHNICAL PROCEDURE PERFORMED: Ileorectal anastomosis, incisional hernia
repair, and the anastomosis was created with a 25 mm circular stapler in an
end-to-end fashion.
:
DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area
where consents and site verification forms were reviewed. Questions were
answered. Risks and benefits of the procedure were explained to include
bleeding, infection, damage to surrounding structures, need for repeat
procedures, possible anastomotic leak, and risks of anesthesia. She agreed and
wished to proceed. She was taken to the Operating Room, placed on the Operating
Room table in the lithotomy position. After general anesthesia had been
induced and a Foley catheter was placed, a rectal washout was performed. An
operative timeout was discussed and the procedure began. We initially began by
making a 7 cm lower midline incision using a #10 blade and dissecting taking
down through the subcutaneous tissue. We entered into the abdomen under direct
vision and took down some filmy adhesions that were noted from the omentum to
the anterior abdominal wall. Once we cleared all the adhesions, we placed a
Gelport into the incision and placed a 12 mm trocar just inferior to the
umbilicus for the camera port. We then began our pneumoperitoneum and took down
additional adhesions using the EnSeal device after a 5 mm trocar was placed in
the left lower quadrant. We then placed another 5 mm trocar in the right lower
quadrant and began the mobilization process of the right and left colon. The
right colon was noted to be absent given the patient had a previous right
hemicolectomy and the hepatic flexure was then mobilized medially by dividing
the lateral attachments using the EnSeal device. The omentum coming from the
transverse colon was previously excised prior to beginning laparoscopically and
the remaining omentum was divided using the EnSeal device as well and the
hand-assist technique. The left colon was taken down using the EnSeal device as
well from a lateral to medial aspect and the mesentery was divided using the
EnSeal device as well to the transverse colon. The middle colic vessels were
identified. These were taken high given this was a potential cancer case in
order to get adequate lymph nodes. We continued along the mesentery of the
transverse colon until we fully mobilized the colon and we were able to bring
the transverse and descending colon out through the lower midline incision. We
then identified an area just proximal to the ileocolic anastomosis and divided
this using a Furness clamp and identified another area at the rectosigmoid
junction and divided this in a similar fashion using a Furness clamp as well.
The colon was then sent off to the pathologist as a specimen. The anvil of the
circular stapler was then placed into the proximal aspect of the small bowel and
secured using the Monosof sutures that had been previously placed using the
Furness clamp. We then used a 25 mm stapler and brought this in through the
patient's anus and up into the rectum and deployed the spike, secured the
divided area of the rectosigmoid junction, and secured this portion of the
rectum to the spike using the previously placed Monosof sutures. The ileum was
then secured to the rectosigmoid junction and the anastomosis was created. An
air leak test was performed and this was negative. There were adhesions to the
small bowel, which prevented us from fully mobilizing this and these were taken
down sharply without injury to the small bowel. We then instilled local
anesthetic in the fascia. Prior to closing, we noticed there was a large
incisional hernia noted at the superior aspect of the patient's previous
incision. This was closed primarily using running #1 PDS suture and the fascia
was closed in a similar fashion from above and below. The skin was then closed
with 4-0 Monocryl subcuticular sutures and the trocar sites were also closed in
a similar fashion using 4-0 Monocryl. Dermabond was placed over the incision.
The patient tolerated the procedure well
PROCEDURE PERFORMED: Laparoscopic subtotal colectomy with ileorectal
anastomosis and incisional hernia repair..
POSTOPERATIVE DIAGNOSIS: Colon adenoma.
.
TECHNICAL PROCEDURE PERFORMED: Ileorectal anastomosis, incisional hernia
repair, and the anastomosis was created with a 25 mm circular stapler in an
end-to-end fashion.
:
DESCRIPTION OF PROCEDURE: The patient was met in the preoperative holding area
where consents and site verification forms were reviewed. Questions were
answered. Risks and benefits of the procedure were explained to include
bleeding, infection, damage to surrounding structures, need for repeat
procedures, possible anastomotic leak, and risks of anesthesia. She agreed and
wished to proceed. She was taken to the Operating Room, placed on the Operating
Room table in the lithotomy position. After general anesthesia had been
induced and a Foley catheter was placed, a rectal washout was performed. An
operative timeout was discussed and the procedure began. We initially began by
making a 7 cm lower midline incision using a #10 blade and dissecting taking
down through the subcutaneous tissue. We entered into the abdomen under direct
vision and took down some filmy adhesions that were noted from the omentum to
the anterior abdominal wall. Once we cleared all the adhesions, we placed a
Gelport into the incision and placed a 12 mm trocar just inferior to the
umbilicus for the camera port. We then began our pneumoperitoneum and took down
additional adhesions using the EnSeal device after a 5 mm trocar was placed in
the left lower quadrant. We then placed another 5 mm trocar in the right lower
quadrant and began the mobilization process of the right and left colon. The
right colon was noted to be absent given the patient had a previous right
hemicolectomy and the hepatic flexure was then mobilized medially by dividing
the lateral attachments using the EnSeal device. The omentum coming from the
transverse colon was previously excised prior to beginning laparoscopically and
the remaining omentum was divided using the EnSeal device as well and the
hand-assist technique. The left colon was taken down using the EnSeal device as
well from a lateral to medial aspect and the mesentery was divided using the
EnSeal device as well to the transverse colon. The middle colic vessels were
identified. These were taken high given this was a potential cancer case in
order to get adequate lymph nodes. We continued along the mesentery of the
transverse colon until we fully mobilized the colon and we were able to bring
the transverse and descending colon out through the lower midline incision. We
then identified an area just proximal to the ileocolic anastomosis and divided
this using a Furness clamp and identified another area at the rectosigmoid
junction and divided this in a similar fashion using a Furness clamp as well.
The colon was then sent off to the pathologist as a specimen. The anvil of the
circular stapler was then placed into the proximal aspect of the small bowel and
secured using the Monosof sutures that had been previously placed using the
Furness clamp. We then used a 25 mm stapler and brought this in through the
patient's anus and up into the rectum and deployed the spike, secured the
divided area of the rectosigmoid junction, and secured this portion of the
rectum to the spike using the previously placed Monosof sutures. The ileum was
then secured to the rectosigmoid junction and the anastomosis was created. An
air leak test was performed and this was negative. There were adhesions to the
small bowel, which prevented us from fully mobilizing this and these were taken
down sharply without injury to the small bowel. We then instilled local
anesthetic in the fascia. Prior to closing, we noticed there was a large
incisional hernia noted at the superior aspect of the patient's previous
incision. This was closed primarily using running #1 PDS suture and the fascia
was closed in a similar fashion from above and below. The skin was then closed
with 4-0 Monocryl subcuticular sutures and the trocar sites were also closed in
a similar fashion using 4-0 Monocryl. Dermabond was placed over the incision.
The patient tolerated the procedure well