is not the only perplexing situation in this op report? I'm hoping to be on the right road here. Any thoughts would be greatly appreciated! Sorry, it's such a lengthy read.
The codes we're leaning to are:
15734 560.9 560.81
15734-XS 560.9 560.81
44346 569.69
PREOPERATIVE DIAGNOSIS
Partial small-bowel obstruction with large paracolostomy hernia.
POSTOPERATIVE DIAGNOSIS:
Partial small-bowel obstruction with large paracolostomy hernia.
OPERATIVE PROCEDURE
Exploratory laparotomy with extensive lysis of adhesions, lasting at least an hour, with takedown of colostomy, partial colectomy with repositioning of the colostomy to the right lower quadrant with repair of a paracolostomy
hernia with component separation and also reconstruction of anterior abdominal wall.
OPERATIVE FINDINGS
The patient had a huge parastomal hernia around his sigmoid colostomy He also had a partial small-bowel obstruction, which was not because of the stomal hernia, but because he had a solitary adhesive band which represented a bowstring on the small-bowel mesentery. I am sure this was a point at which small bowel was intermittently and partially being obstructed. The bowel above this area was markedly dilated. In addition, there were adhesions from the omentum to the large hernia defect in the left lower quadrant and to the anterior abdominal wall in the lower abdomen and pelvis. There was evidence of a previous distal small-bowel obstruction with ileal to ascending colostomy
DESCRIPTION OF PROCEDURE
Under general anesthesia, the colostomy in the left lower quadrant was sutured close and the patient's abdomen was prepped and sterilely draped. The previous midline skin scar was excised, fascia incised and the peritoneal
cavity entered. We then used the LigaSure to resect the adherent omentum from the anterior abdominal wall and also from the margins of the hernia defect in the left lower quadrant At the same time, we also reduced multiple
loops of small bowel which were within the hernia sac. We ended up excising redundant omentum by using the LigaSure. We then transected the sigmoid colon proximal to its exit from the anterior abdominal wall with the GIA
stapler We then mobilized the descending colon by incising the lateral peritoneal reflection along the white line of Toldt and took down the splenic flexure. The splenocolic ligaments were divided with the LigaSure and the
omentum dissected off of the transverse colon. At this point, we had enough mobility of the colon after taking down the hepatocolic ligament to bring it out at a preselected area in the right lower quadrant, but this would have
resulted in some redundancy and possible kinking of the colon at the hepatic flexure, so I decided to excise about 6 inches of it, which I did using the GIA stapler and divided the mesentery with the LigaSure. I then dissected the
hernia sac off of the anterior abdominal wall and then divided the abdominal component on the left side, incising it with cautery and bluntly dissecting fibers that connected the anterior sheath to the internal oblique layer to mobilize the fascia towards the midline. Same procedure was carried out on the right side. It should be noted that the dissection went from the costal margin down to the pubis We then lined up the abdominal fascia with some 0
Prolenes and then selected a spot where I was going to bring the bowel through the abdominal wall as the new colostomy and excised a button of skin at that site in the right lower to mid abdomen. Fascia was divided in a
cruciate fashion. Bowel was then brought through at this level. We then sutured the midline abdominal fascia with interrupted #1 Prolene sutures. There was some moderate amount of tension, but I did not think it was excessive. It should be noted that there was a rim of fascia medial to the fascia that constituted the lateral aspect of the hernia defect and these 2 fascial structures had been previously reapproximated with running #1 Prolene suture. We then approximated the midline, as I said, with #1 Prolene. We then put a__ Prolene soft mesh, large piece, 14 x 11 inches, which was then brought across the anterior abdominal wall, tacked to the lateral fascia on either side with absorbable tacks. BioGlue was spread on the mesh. Two 19 Jackson-Pratt drains were placed in the gutter on either side of the abdominal wall superficial to the mesh. Subcutaneous tissue was closed with interrupted 2-0 Vicryl Skin was closed with skin staples We then excised the redundant skin in the left lower quadrant where the colostomy had been. It should be noted that the colostomy itself was excised completely from the skin prior to this, and we excised a large piece of ellipse of skin, encompassing most of the redundant skin that had been created by the large hernia. Subcutaneous tissue at that level was closed with interrupted 2-0 Vicryl Skin was closed with running 3-0 nylon locking suture. The colostomy was then matured in Brooke fashion with 4-0 Vicryl The patient tolerated the procedure well, left the operating room in good condition.
The codes we're leaning to are:
15734 560.9 560.81
15734-XS 560.9 560.81
44346 569.69
PREOPERATIVE DIAGNOSIS
Partial small-bowel obstruction with large paracolostomy hernia.
POSTOPERATIVE DIAGNOSIS:
Partial small-bowel obstruction with large paracolostomy hernia.
OPERATIVE PROCEDURE
Exploratory laparotomy with extensive lysis of adhesions, lasting at least an hour, with takedown of colostomy, partial colectomy with repositioning of the colostomy to the right lower quadrant with repair of a paracolostomy
hernia with component separation and also reconstruction of anterior abdominal wall.
OPERATIVE FINDINGS
The patient had a huge parastomal hernia around his sigmoid colostomy He also had a partial small-bowel obstruction, which was not because of the stomal hernia, but because he had a solitary adhesive band which represented a bowstring on the small-bowel mesentery. I am sure this was a point at which small bowel was intermittently and partially being obstructed. The bowel above this area was markedly dilated. In addition, there were adhesions from the omentum to the large hernia defect in the left lower quadrant and to the anterior abdominal wall in the lower abdomen and pelvis. There was evidence of a previous distal small-bowel obstruction with ileal to ascending colostomy
DESCRIPTION OF PROCEDURE
Under general anesthesia, the colostomy in the left lower quadrant was sutured close and the patient's abdomen was prepped and sterilely draped. The previous midline skin scar was excised, fascia incised and the peritoneal
cavity entered. We then used the LigaSure to resect the adherent omentum from the anterior abdominal wall and also from the margins of the hernia defect in the left lower quadrant At the same time, we also reduced multiple
loops of small bowel which were within the hernia sac. We ended up excising redundant omentum by using the LigaSure. We then transected the sigmoid colon proximal to its exit from the anterior abdominal wall with the GIA
stapler We then mobilized the descending colon by incising the lateral peritoneal reflection along the white line of Toldt and took down the splenic flexure. The splenocolic ligaments were divided with the LigaSure and the
omentum dissected off of the transverse colon. At this point, we had enough mobility of the colon after taking down the hepatocolic ligament to bring it out at a preselected area in the right lower quadrant, but this would have
resulted in some redundancy and possible kinking of the colon at the hepatic flexure, so I decided to excise about 6 inches of it, which I did using the GIA stapler and divided the mesentery with the LigaSure. I then dissected the
hernia sac off of the anterior abdominal wall and then divided the abdominal component on the left side, incising it with cautery and bluntly dissecting fibers that connected the anterior sheath to the internal oblique layer to mobilize the fascia towards the midline. Same procedure was carried out on the right side. It should be noted that the dissection went from the costal margin down to the pubis We then lined up the abdominal fascia with some 0
Prolenes and then selected a spot where I was going to bring the bowel through the abdominal wall as the new colostomy and excised a button of skin at that site in the right lower to mid abdomen. Fascia was divided in a
cruciate fashion. Bowel was then brought through at this level. We then sutured the midline abdominal fascia with interrupted #1 Prolene sutures. There was some moderate amount of tension, but I did not think it was excessive. It should be noted that there was a rim of fascia medial to the fascia that constituted the lateral aspect of the hernia defect and these 2 fascial structures had been previously reapproximated with running #1 Prolene suture. We then approximated the midline, as I said, with #1 Prolene. We then put a__ Prolene soft mesh, large piece, 14 x 11 inches, which was then brought across the anterior abdominal wall, tacked to the lateral fascia on either side with absorbable tacks. BioGlue was spread on the mesh. Two 19 Jackson-Pratt drains were placed in the gutter on either side of the abdominal wall superficial to the mesh. Subcutaneous tissue was closed with interrupted 2-0 Vicryl Skin was closed with skin staples We then excised the redundant skin in the left lower quadrant where the colostomy had been. It should be noted that the colostomy itself was excised completely from the skin prior to this, and we excised a large piece of ellipse of skin, encompassing most of the redundant skin that had been created by the large hernia. Subcutaneous tissue at that level was closed with interrupted 2-0 Vicryl Skin was closed with running 3-0 nylon locking suture. The colostomy was then matured in Brooke fashion with 4-0 Vicryl The patient tolerated the procedure well, left the operating room in good condition.