I have coded this surgery with the following codes. I still feel that I am missing something. Is something not correct?
1. Sigmoid proctocolectomy with low pelvic anastomosis. C(pt 44145)
2. Excision of left ovarian or fallopian tube cyst, simple. (Cpt 58925 lt xu)
3. Primary repair of the left ureter. (Cpt 50800 lt xu)
4. Bilateral subfascial blocks to the abdominal wall with Exparel for
local pain control. included in surgery
After informed consent was obtained from
the patient, the patient was taken to the operating room. She was placed
on the operating table in the supine position and general anesthesia was
induced. After induction of the general anesthesia, the patient's position
on the table was switched to a modified Lloyd Davis position. A small
suprapubic midline incision was made using a #10 scalpel blade, incision
was taken down to the linea alba, which was divided. Access to the
peritoneal cavity was obtained. The peritoneal cavity was inspected. The
patient had some interloop abscesses into a solid mass in the sigmoid
colon, which by the desmoplastic reaction observed, might well be a
malignant neoplasm. The interloop abscesses were then carefully separated
from the mesenteric border of the colon and at this point, a small amount
of purulent exudate was drained. Once the small bowel was completely
separated, then we proceeded to mobilize the best possible way. The
sigmoid colon from lateral to medial, the peritoneal attachments were
divided. There was a significant desmoplastic reaction right where the
mass was located, that extended into the retroperitoneum. The external
iliac artery as well as the hypogastric were clearly identified. The
ureter appears to be embedded into that desmoplastic reaction. Using
mostly blunt dissection, the ureter was carefully separated; however, while
doing that, a small tear appeared and the lumen of the ureter was visible.
Therefore, I decided to repair it primarily using 5-0 PDS interrupted
sutures using triangulation technique. Prior to completion of the last two
sutures, it was verified that there was patency on both sides of the
ureter. The repair appeared to be intact. Once we managed to separate the
ureter from this desmoplastic reaction of the retroperitoneum, we then
continued to mobilize the descending colon to just close through the
splenic flexure. Attached to the left fallopian tube and embedded into
this colonic mass, there appeared to be a simple cyst coming from either
the fallopian tube or the ovary. Using the LigaSure device, the entire
simple cyst was completely excised. With this maneuver, we managed to get
access to the peritoneal reflection. The mesentery was scored and the
proximal and distal ends of our resection was selected. A window was
created on the descending colon and a Glassman clamp was placed proximally
and a Kocher clamp distally and the colon was transected. The mesentery
was then taken down using LigaSure device, trying to obtain as much of the
mesenteric lymph nodes as possible for good node sampling. Her incision
was then extended correcting our dissection of the colonic mesentery, was
extended all the way down to the peritoneal reflection where the rectum was
skeletonized and at this point, the rectum was divided using a 45 mm
contour device. A pursestring was then created on the descending colon and
a 29 mm anvil was placed on the descending colon once the pursestring had
been completed with 3-0 Prolene suture. We then proceeded to complete a
transanal proctocolostomy anastomosis. Once the anastomosis was completed,
the descending colon was controlled with a Glassman clamp and the
anastomosis was tested using the rigid proctosigmoidoscope to pressure with
air and fluid. There was no leakage. I was able to observe a widely patent
anastomosis with a rigid proctoscope. The abdominal cavity was then
irrigated profusely. All the irrigation was suctioned out. I decided to
leave a 19-French round Blake drain towards the left side of the pelvis
because of the ureteral tear just to monitor it. The drain was secured to
skin using 2-0 nylon sutures. The position of the nasogastric tube was
verified to be in the stomach. The fascia was closed using continuous
sutures of 0 Stratafix. Bilateral subfascial blocks to the abdominal wall
using Exparel and Marcaine were placed for local pain control. The wound
was irrigated and the skin was closed using surgical staples and negative
pressure dressing with a Prevena was placed. The patient has tolerated the
procedure well and has been transferred to the recovery room in stable
condition.
1. Sigmoid proctocolectomy with low pelvic anastomosis. C(pt 44145)
2. Excision of left ovarian or fallopian tube cyst, simple. (Cpt 58925 lt xu)
3. Primary repair of the left ureter. (Cpt 50800 lt xu)
4. Bilateral subfascial blocks to the abdominal wall with Exparel for
local pain control. included in surgery
After informed consent was obtained from
the patient, the patient was taken to the operating room. She was placed
on the operating table in the supine position and general anesthesia was
induced. After induction of the general anesthesia, the patient's position
on the table was switched to a modified Lloyd Davis position. A small
suprapubic midline incision was made using a #10 scalpel blade, incision
was taken down to the linea alba, which was divided. Access to the
peritoneal cavity was obtained. The peritoneal cavity was inspected. The
patient had some interloop abscesses into a solid mass in the sigmoid
colon, which by the desmoplastic reaction observed, might well be a
malignant neoplasm. The interloop abscesses were then carefully separated
from the mesenteric border of the colon and at this point, a small amount
of purulent exudate was drained. Once the small bowel was completely
separated, then we proceeded to mobilize the best possible way. The
sigmoid colon from lateral to medial, the peritoneal attachments were
divided. There was a significant desmoplastic reaction right where the
mass was located, that extended into the retroperitoneum. The external
iliac artery as well as the hypogastric were clearly identified. The
ureter appears to be embedded into that desmoplastic reaction. Using
mostly blunt dissection, the ureter was carefully separated; however, while
doing that, a small tear appeared and the lumen of the ureter was visible.
Therefore, I decided to repair it primarily using 5-0 PDS interrupted
sutures using triangulation technique. Prior to completion of the last two
sutures, it was verified that there was patency on both sides of the
ureter. The repair appeared to be intact. Once we managed to separate the
ureter from this desmoplastic reaction of the retroperitoneum, we then
continued to mobilize the descending colon to just close through the
splenic flexure. Attached to the left fallopian tube and embedded into
this colonic mass, there appeared to be a simple cyst coming from either
the fallopian tube or the ovary. Using the LigaSure device, the entire
simple cyst was completely excised. With this maneuver, we managed to get
access to the peritoneal reflection. The mesentery was scored and the
proximal and distal ends of our resection was selected. A window was
created on the descending colon and a Glassman clamp was placed proximally
and a Kocher clamp distally and the colon was transected. The mesentery
was then taken down using LigaSure device, trying to obtain as much of the
mesenteric lymph nodes as possible for good node sampling. Her incision
was then extended correcting our dissection of the colonic mesentery, was
extended all the way down to the peritoneal reflection where the rectum was
skeletonized and at this point, the rectum was divided using a 45 mm
contour device. A pursestring was then created on the descending colon and
a 29 mm anvil was placed on the descending colon once the pursestring had
been completed with 3-0 Prolene suture. We then proceeded to complete a
transanal proctocolostomy anastomosis. Once the anastomosis was completed,
the descending colon was controlled with a Glassman clamp and the
anastomosis was tested using the rigid proctosigmoidoscope to pressure with
air and fluid. There was no leakage. I was able to observe a widely patent
anastomosis with a rigid proctoscope. The abdominal cavity was then
irrigated profusely. All the irrigation was suctioned out. I decided to
leave a 19-French round Blake drain towards the left side of the pelvis
because of the ureteral tear just to monitor it. The drain was secured to
skin using 2-0 nylon sutures. The position of the nasogastric tube was
verified to be in the stomach. The fascia was closed using continuous
sutures of 0 Stratafix. Bilateral subfascial blocks to the abdominal wall
using Exparel and Marcaine were placed for local pain control. The wound
was irrigated and the skin was closed using surgical staples and negative
pressure dressing with a Prevena was placed. The patient has tolerated the
procedure well and has been transferred to the recovery room in stable
condition.
