I could use some help on coding an operative note, i feel like i am totally missing something in this report I have read it so many times and have even put it away and come back to it.

Postoperative Diagnoses:
Diffuse carcinomatosis with small bowl obstruction, distal small bowel and right lower quadrant, and extensive flank and pelvic tumor deposits.

Procedure:
Exploratory laparotomy with release of the distal small bowel obstruction with side-to-side distal small bowel to proximal transverse colon anatomosis internal bypass.

Indication:
The patient is a 78 year old with right colon CA with diffuse carcinomatosis with small bowel obstruction secondary to tumor, here for exploratory laparotomy.

Description of operation:
The patient was brought to the operating room and placed on the table in supine position. Following general endoctracheal anesthesia the abdomen was prepped and draped in the usual fashion under sterile technique. Mid line incision was made above and below the umbilicus. Dissection carried down to the fascia and peritoneum was entered without difficulty. The small bowel appeared to be intact and no significant tumor involvement except area of right lower quadrant causing small bowel obstruction adjacent to the cecum. This was mobilized and freed and serosal defect was over sewn with 3-0 chromic and interrupted 3-0 silk suture over a 2 cm area. The patient had extensive tumor involving the right colon and the lateral left flank area as well. The colon appeared to be intact without obstruction, extending down into the rectum. The patient did have stool in the transverse colon as well. It was felt that the colon distal to the ascending colon appeared to be viable and functional, felt internal bypass between distal small bowel and the proximal transverse colon was indicated. The small bowel side-to-side to proximal transverse colon was hand sew outer interrupted 3-0 silk suture and a running 3-0 chromic suture over the anastomosis __cm in length and appeared to be open and then tacked. Bowel was placed back in normal anatomic position. Omental implant was excised and sent to pathology for permanent section as well. Umbilical tumor was excised and the fascia was then closed with running looped 0 PDS suture. Skin approximated with staples. Blood loss was appox 20 ml. She tolerated well and returned to recovery in stable condition. ___exploratory laparotomy with internal bypass, small bowel to the proximal transverse colon, repair of serosal tear, and release of distal small bowel obstruction.

I came up with
44130 with DX c18.2
44604 with DX S36.538A

Thanks for any help and suggestions