After general endotracheal anesthesia, patient was positioned in supine position. The colostomy was closed with a running 2-0 silk suture. The patient was prepped and draped in the usual sterile fashion. A 10 blade scalpel was used for skin incision extending subxiphoid down to the pubic symphysis. The subcutaneous tissue was dissected using cautery down to the linea alba. The linea alba was then opened under direct visualization was extended superiorly and inferiorly. Edges of the fascia was grasp with Kockers and lysis of adhesions were carried out using cautery. A Balfour retractor was then placed with good exposure. A loop of small bowel was tethered to the pelvis, bladder and rectal stump. This loop was mobilized out of the pelvis with sharp dissection and cautery. After freeing the entire small bowel, it was inspected for any injuries. The loop of small bowel in the pelvis appeared to be thickened from previous radiation with serosal tears. The serosal tears were attempted to be over sewn with 3.0 vicryl but would tear and not hold sutures. I suspect from previous radiation damage. I then decided to resect this loop of distal ilium measuring approximately 15 cm. Using a GIA stapler the proximal and distal ends of the loop were divided. The small bowel then was aligned in a side to side fashion with 3.0 silk sutures. End enterotomies were performed using cautery. A 75cm GIA was placed in the enterotomies creating a side to side anastomosis. The end enterotomies were aligned with Alice graspers and closed using a TX 60 stapler. Once the small bowel had been mobilized out of the pelvis and resected, the rectum was attempted to be identified however is very thickened peritoneum the as well as bladder. The first assist placed rectal dilators in the rectum for easier palpation and mobilization. However, the previous staple line was unable to be identified. The peritoneum was thicken but the rectum could be palpated. An elliptical skin incision was performed around the colostomy and the subcutaneous tissues dissected to the fascia. Patient was noted to have a parastomal hernia and the hernia sac was also dissected free and transected. The proximal colon then was able to be mobilized intra-abdominally from the ostomy site. The proximal colon was transected using the a 75 GIA stapler to healthy appearing colonic tissue. An EEA 29 mm anvil was secured in the proximal end with a #1 PDS using a pursestring. The EEA stapler was then placed transrectally. The spiked end was barely visible secondary to the thickened wall. The rectal stump was attempted to be skeletonalized by scoring the perirectal fat and peritoneum. There appeared blood in the foley catheter. The first assist back filled the catheter no leak. Continued dissection revealed the bladder was draped over the rectum. I was unable to separate the bladder from the rectum. The posterior bladder wall had been opened during this dissection. The bladder was closed in a 2 layered fashion. First layer was closed using 3-0 chromic and the second layer with 3-0 Vicryl. A #19 French Blake drain was then placed in the pelvis exiting the left lower quadrant and secured to the skin with a 2-0 silk suture. The colo-rectal anastomosis was then abandoned secondary to frozen pelvis and inability to mobilize the rectum to make the anastomosis. The previous ostomy site hernia was closed using 1.0 PDS for the posterior rectus sheath and a 1.0 Vicryl on the anterior rectus sheath. A new ostomy site was created in the right lower quadrant. Using an Alice grasper, the skin was incised in a circular manor. The subcutaneous tissue was dissected using cautery. The anterior rectus sheath was opened two finger breaths and dilated. The sigmoid colon was then delivered through this opening. Copious irrigations were applied and meticulous hemostasis was maintained throughout the procedure. All needles and sponge counts were correct ×2. The midline fascia was closed using a running #1 PDS superiorly and inferiorly. The subcutaneous tissue was irrigated. The skin was then closed using staples. The left ostomy site was also closed with staples. The newly relocated ostomy in the right lower quadrant was then matured using 3.0 vicryl sutures and a clostomy bag was placed. Sterile dressing was applied and the patient was transferred to recovery room in stable condition.
Colonstomy location revision, small bowel resection, bladder repair
Hello! Any suggestions on how to code this? I am looking at 44346, but then would I just bill the 44120 for the small bowel. I know the bladder repair, and adhesiolysis is included.
