Wiki Ileocecal Resection

[tcooper@nmhs.net]

Good Afternoon. Would someone help me with this coding problem please?
Patient was in a Motor Vehicle Accident where he had a small bowel eviscerated from the right midabdominal area where he had a puncture wound. Patient had a through-and-through injury to the cecum. Surgeon performed an anastamosis between the small bowel and the ascending colon. Once this was done he wrapped this in omentum and placed omentum down into the retroperitoneal area.
What code do you think would appropitate for this procedure. Thank you in advance for your help.
Teresa Cooper, CGSC

 

[CarolinaSunshine]

Look at 44160 for the ileocecal resection (ileocecectomy)
Description: The physician makes an abdominal incision and removes a segment of the colon and terminal ileum and performs an anastomosis between the remaining ileum and colon. The physician makes an abdominal incision. Next, the selected segment of colon and terminal ileum are isolated and divided proximal and distal to the remaining bowel and removed. An anastomosis is created between the distal ileum and remaining colon with staples or sutures. The incision is closed.
I'm not sure about the omental procedure without reading the op note. If the physician did an "omental flap", you can use +49905. These are normally done with stomach procedures, duodenum procedures, or to protect an intestinal anastomosis. It is also known as a "graham patch". However, physicians pull omentum down over the intestinal area after procedures normally, so there would be no charge for this. In order to perform an "omental flap"--he needs to go into detail about how this was done. The description of the procedure is: The omentum is dissected from the transverse colon from left to right and small vessels are ligated. When completely separated from the transverse colon, the omentum is dissected from the stomach with careful clamping, division, and ligation of vessels. The omentum is fully mobilized and pedicled on the right or left gastroepiploic vessel, depending on the purpose. More incisions and tunneling may be necessary to bring the flap into its new location to fill a defect.
If he doesn't go into this detail, I would not charge for this portion. It would be included in the 44160.

 

[igrigoras@iowaclinic.com]

Hello, any second opinion on the below surgery, will be greatly appreciated:
Operation:

1. Intraoperative colonoscopy
2. Open sigmoid colon resection
3. Cecostomy take-down
4. Ileocecectomy
5. Lysis of adhesions greater than 2 hours
6. Incisional hernia repair with scar revision.
   
   Findings:
   1. Intraoperative colonoscopy with sigmoid diverticulosis and stricture. No masses, lesions, polyps. No findings of malignancy.
   2. Benign-appearing diverticular stricture. Significant adhesive disease.
   3. Unremarkable cecostomy.
      Beginning with the intraoperative colonoscopy, the ostomy bag was opened and the scope was passed through the cecostomy into the cecum. The appendiceal orifice was directly identified and the ileocecal valve was noted to be very close to the cecostomy, which made it difficult to visualize well. The colonoscope was then passed through the ascending, transverse, descending, and sigmoid: Until the rectum was reached. There was a point around the sigmoid colon that was very narrowed and the scope was nearly unable to pass. The prep was good and all mucosal surfaces were visualized adequately during scope withdrawal. She was noted to have multiple small mouth diverticula of the sigmoid colon. There were no masses, lesions, or polyps identified. The colonic mucosa was noted to be delicate secondary to complete diversion of luminal contents. The scope was then withdrawn and the ostomy appliance was removed.
   
   The patient was then placed in yellowfin stirrups and her abdomen was prepped and draped in the usual sterile fashion. An incision was created by excising the patient's prior scar (approximately 17 x 4 cm). Below the scar, there was minimal tissue and the peritoneal cavity was entered carefully to avoid underlying adherent small bowel. Using Simms scissors, extensive lysis of adhesions was performed, meticulously freeing the small bowel off of the anterior abdominal wall and up out of the pelvis. An Alexis wound protector was then placed into the incision. Next, the sigmoid colon stricture was identified and found to be densely adherent to the abdominal sidewall. There were no findings of malignancy. This was also taken down sharply using Simms scissors, taking care not to injure the left ureter. The descending and sigmoid colon were then mobilized laterally at the white line of Toldt. Proximally on the descending colon, a transection point was selected and the fat was cleared circumferentially around the bowel. Clean towels were placed around the incision. A Furness clamp was then placed and a Keith needle with 2-0 Prolene suture was threaded through to create an even pursestring. The bowel was then divided using a curved Mayo scissors. The anvil placed inside and the pursestring was tied down. The mesentery of the sigmoid colon was then divided using a LigaSure Impact device down to the level of the rectum where splaying of the tinea was identified. Here, the bowel was divided using a 40 mm green contour stapler. The specimen was back table where it was opened. This demonstrated a benign-appearing stricture. Next, the sizers were used to dilate and measure the rectum. After confirming length and orientation of the descending colon, a 28 mm EEA stapler was used to create an end-to-end stapled anastomosis. The donuts were inspected and found to be intact. The anastomosis was checked by submerging it and insufflating the rectum with air. There was no evidence of air bubbles indicating a leak.
   
   Using electrocautery, the cecostomy was excised and transverse ellipse orientation. The cecostomy was carefully dissected from the subcutaneous attachments using both sharp dissection and electrocautery. Once freed, three 80 mm blue loads in a GIA stapler were used to divide the terminal ileum and ascending colon as well as create a common channel for a stapled antiperistaltic side-to-side anastomosis. The enterotomy was then closed using a 90 mm blue load and a TA stapler setting the staple lines and checking for hemostasis. The anastomosis was checked and found to be intact and widely patent. A crotch stitch was placed and the mesenteric defect was closed using a 3-0 Vicryl suture.
   
   Lastly, the closing tray was used to close the midline incision and cecostomy site. In order to perform a satisfactory fascial closure, a significant amount of attenuated fascia was trimmed. Subcutaneous flaps were created and the fascia was closed using two #1 PDS sutures in a running fashion towards midline. Both wounds were gently irrigated. A large Penrose drain then placed in the subcutaneous tissues and brought out of the incision inferiorly. This was sutured in place using two interrupted stitches of 4-0 Monocryl suture. The skin was closed using a skin stapler. The fascia of the cecostomy site was closed using a running #1 PDS suture. The incision was partially closed at either side of the ellipse using interrupted stitches of 4-0 Monocryl suture. A small amount of surgical skin glue was placed over top of these corners.