Procedure: Laparoscopic sigmoidectomy
Postoperative Diagnosis: Recurrent sigmoid volvulus
Description of Procedure: Patient is brought to the operating room, placed supine on operating table. General anesthesia was induced without complications and patient was placed in low lithotomy position. Patient was then prepped and draped in usual sterile fashion. A left mid quadrant incision was made with 15 blade and using the 11 mm Ethicon Excel trocar, this was placed into the peritoneal cavity under direct vision. Gas was insufflated into the abdomen after confirming that we are in the peritoneal cavity with the camera. There were no gross abnormalities seen. Two additional trocars were placed under direct visualization, 12 mm in right lower quadrant and 5 mm in right mid area. The patient was placed in Trendelenberg position and the small bowel is retracted out of the way. Patient had a very redundant and long sigmoid. We scored the mesentery of the distal sigmoid and proximal rectum and isolated the colonic wall. The peritoneum was thick even though the mesentery was not. We then stapled across the proximal rectum. It was wide. We then dissected the mesentery up toward the proximal sigmoid where the mesentery was tethered and fixed. There was long redundancy of the sigmoid, at least 2 feet. We clipped proximal vessels and ligated mesentery with the Ligasure. Patient did have lateral attachments of the descending colon but lower in the mesentery, not at the colonic wall, and the mesentery is long so the colon does continue to migrate up and down. The proximal margin was measured for distance from the tumor and for adequate length for reanastomosis. Using a scalpel, we opened up a lower pelvic wound and dissected down. The anterior fascia was opened up a lower pelvic wound and dissected down. The anterior fascia was opened up and the rectus muscle retracted medially. The posterior fascia was opened up and the wound protector was placed. The distal end of the sigmoid colon was pulled through the wound until it was restricted. The mesentery was ligated up to the colonic wall. The proximal colon was transected with stapler and specimen sent off the table. The staple line was opened up and measured for 31 EEA. A running baseball stitch suture was placed with 2-0 prolene and the anvil was tied down. The base was cleaned off for the anastomosis. No diverticuli was present on the base. We then placed the remaining colon back into the abdominal cavity. Gloves were changed and the wound protector was removed. The posterior fascia was reapproximated with 0- vicryl in running fashion. The wound was irrigated and dried. The anterior fascia was reapproximated with 0-PDS in running fashion. Gas was reinsufflated into the abdominal cavity.
The EEA stapler was placed into the rectum and maneuvered until it was at the end of the staple line and flat. The spike was pierced through and the anvil was attached and secured. The colon was checked to make sure it was not twisted or kinked. The EEA stapler was closed. One final check was performed and the stapler was fired. The stapler was opened and slowly removed from the rectum. There were two intact donuts on inspection and these were sent as proximal and distal margin. The pelvis was irrigated clear and irrigant was placed. The proctosigmoidoscope was replaced and air was insufflated after clamping proximal to the anastomosis. There was no evidence of leakage. No bleeding seen through the scope. The air was removed and the proctoscope was removed. The area was suction cleaned. The gutters were inspected and suction dried. The mesentery was tethered but the bowel was not. So we sutured secured the bowel to the side pelvic wall and sutured the mesenteric peritoneal edges to secure it in place. The bowel was replaced. The trocars were then removed under direct visualization. The wounds were irrigated and dried. Hemostasis was achieved with electrocautery. The skin was closed with 4-0 vicryl. The wounds were cleaned and dried and dressed with steristrips and clean dressing.
• Based on your review of the operative report, what body system and root operation would you select?
• Based on your responses to the first question, what is the
• Based on your review of the operative report, what is the approach?
• According to the operative report, did the procedure also include an open approach? Which guideline would guide your final approach selection?
• What code(s) is assigned?
1.All characters in ICD-10 PCS are seven characters ,which comprises of section,body system,root operation ,body part,approach,device and qualifier.Body system-
2 Section -Medical surgical=. 0
Body systems-D - Gastrointestinal system.
Body part =N
3 The approach used is Percutaneous Endoscopic approach.
4 No,it used only the Percutaneous Endosopic approach .Aleft mid quadrant incision was made with15 blade and using the 11mm Ethico Excel trocar this was placed into the peritoneal cavity under direct vision This is the guideline which i used to conclude my approach
4. 45331-Sigmoidoscopy ,flexible,with biopsy single or multiple.
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