Naomi Posted Wed 20th of May, 2020 13:01:07 PM
Can someone please advise us how to code for this SX? Op performed: 1. proctosigmoidoscopy 2. laparoscopic lysis of adhesions 3. laparoscopic low anterior resection 4. left ureterolysis 5. splenic flexure takedown 6. placement of cystoscopy and placement of ureteral stent. --A proctosigmoidoscopy was performed with a rigid scope. The lesion was noted to be about 10 cm from the anal verge. This was evidenced by some friability of the tissue and bleeding from the previous tumor recurrence and also radiation changes. An infraumbilical incision was made and 11 mm trocar was inserted under direct vision into the peritoneal cavity. a pneumoperitoneum was created with CO2 gas and the abdomen visually explored. Two other 5 mm and a 12mm trocar were placed in the lower abdomen and lysis of adhesions was begun from his previous surgery. There were very few adhesions noted in the upper abdomen; however, the pelvis was plastered because of the recurrent low anterior resection, the tumor recurrence and also the radiation that had been given preoperatively. Extensive lysing of adhesions had begun. Attempts were made to light the ureter, which was supposed to light up. However, I was unable to find that. Careful, very tedious dissection was then undertaken to identify the left ureter. This was buried in the scar tissue and dissected free. The stent was noted as the ureter was stiff to visual palpation. Hemostasis was meticulous. The colon was mobilized as the walk to the splenic flexure. A portion of the splenic flexure was also lysed as he would need every centimeter of colon. There was no redundancy whatsoever. The pelvis was dissected free then. Both sides of colon were dissected all the way down into the pelvis into the deep true pelvis. Adhesions were noted to the bladder anteriorly, to the sacrum posteriorly and the pelvic side walls. Fatty tissue and mesorectum was included in the dissection to clean the lymph nodes which the patient had. Sharp dissection was undertaken deep into the pelvis. The anastomosis was identified. the was very friable, very difficult to dissect, bloody and fibrotic. With my assistant holding a sizer in the rectum, i was able to dissect around it, so as to prevent injury and perforation. This was adequately achieved. Hemostasis was meticulous at all times. Continued dissection was performed and trhe recum fully mobilized. Once this was performed and the mesorectum dissected posteriorly, a spot was cleaned in the distal rectal region at the spot where I was going to divide the rectum. An Endo-GIA stapler was fired across the rectum with 2 fires of the Endo-GIA blue cartridge and the specimen detached. Further dissection was undertaken and the mesentry mobilized all the way up using the Harmonic scalpel and the ICG was used to check the vascularity of the area. This was noticed to be intact. Once this was performed, a small incision was made in the suprapubic area on the left side and using a rectus muscle splitting incision, the specimen was removed. I was divided using cautery, 3-0 Prolene was used to create at pursestring in the open mouth of the descending colon and a 29 mm EEA anvil was inserted. The pursestring was tightened around the anvil returned into the peritoneal cavity. Once this was performed, my assistant went back down into the rectum and using the Endo GIA stapler, he inserted and Endo-GIA stapler after sizing the rectum with a 29 mm EEA instrument. An end-to-end anastomosis was performed between the descending colon and the rectum. Leak test was performed and found to be adequate. Tisseel was injected. Thorough irrigation performed. All the trocars withdrawn under direct supervision. A 19-French Bake drain was inserted because of the radiated tissue.
SuperCoder Answered Thu 21st of May, 2020 03:06:56 AM