HI,
I have two operative reports (Both are below) and on 10/17/14 the patient had a total abdominal colectomy with no type of anastomosis or ostomy indicated. Then on 10/19/14 the patient had a total protectomy with ileostomy. So basically, the patient had a 44155 which is how I would bill it if it had all been done on 1 day but it was done in two separate surgical sessions and I'm not sure if it can be broken up. Should I bill as 44155 each day with a 52 modifier? Any suggestions would be appreciated.
Date of Service: 10/17/2014
PREOPERATIVE DIAGNOSIS
Free air.
POSTOPERATIVE DIAGNOSIS
1. Transmural necrosis of the left and sigmoid colon.
2. Gross fecal abdominal contamination.
3. Septic shock.
PROCEDURE PERFORMED
1. Total abdominal colectomy.
2. Abdominal washout.
3. Open abdomen with ABThera VAC therapy.
INDICATIONS
Ms. is a 72-year-old female, who underwent a right hip replacement
several weeks ago, and subsequently at rehab developed a cold right
lower extremity and was transferred back to Hospital where she underwent endovascular intervention with multiple iliac stents placed. Over the last several days it was noted that she became kind of progressively distended with increased tympany, and altered mental status. Yesterday afternoon a CAT scan was performed, which showed moderate amounts of free air within the abdomen. Risks and benefits of the procedure were discussed with the wife and her exhusband including significant risk of catastrophic injury and death. The patient agreed at this time to go from urgent exploratory
laparotomy.
OPERATIVE COURSE
After consent was obtained, patient taken to the operating room. General anesthesia was given via endotracheal intubation. A right internal jugular catheter was placed. A left radial A-line was placed. Foley catheter was placed. NG tube was placed. The patient's abdomenwas prepped and draped and timeout was then performed to confirm the correct patient and procedure. A midline abdominal incision was thus made from the xiphoid to the pubic symphysis. Once the skin was incised, dissection was changed to electrocautery down to the level of the anterior fascia and the anterior fascia was incised. The peritoneum was grasped with Kelly clamps x2. It was incised with Metzenbaum scissors. At this time the remaining portion of the abdominal fascia was opened under direct vision with electrocautery. Upon entering the
abdomen there was noted to be several liters of gross liquid stool. The stool was sent for culture and Gram stain. Approximately 4 L of intraabdominal
liquid stool were suctioned from the abdomen. The midline abdominal incision was finished. The Omni retractor was placed at the abdominal wall fascia. Abdominal wall was retracted. At this time it was noted that there was continuous stool soilage in the left lower quadrant. At this time once the omentum was grasped and retracted cephalad exposing the transverse colon, it was noted there was transmural necrosis of the left and sigmoid colon, approximately 20 cm of perforated left and sigmoid colon. The proximal colon was markedly dilated. The cecum was greater than 20 cm. There was no palpable pulse at the ileocecal or right colic artery. At this time, a window was created in the transverse mesocolon. A 75 cm linear cutting stapler was
fired. From this point forward, the left transverse colon mesentery was
taken with the LigaSure. The splenic flexure was mobilized. Again mesentery was taken with the LigaSure. Once around the splenic flexure, the remaining portion of the left colon and descending colon and sigmoid colon mesentery was mobilized with a combination of electrocautery. It was ligated with the LigaSure to the level of the sigmoid colon. At this time, the left ureter was identified and it was swept medially, and again the remaining portion of the sigmoid colon was freed up. The peritoneal reflections were taken down. The peritoneal reflection was opened allowing access to the proximal rectum. The rectum appeared to be intact, viable and without perforation. At this time, a TA-60 was used. At approximately 8-10 cm of remaining rectum a TA-60 was fired and the specimen was sent off the field for permanent pathology.
At this time the abdomen was irrigated with approximately 4 L of warmed
normal saline. All bleeding was controlled with 2-0 silk ties and electrocautery. The rectal stump appeared to be intact. Again the right colon looked gray, remained gray, it was cold to touch, it was markedly dilated with no palpable pulses. At this time it was decided to perform a completion abdominal colectomy. At 10 cm proximal to the cecum on the terminal ileum, a mesenteric window was created with curved hemostats. A linear cutting 60 mm stapler was fired. The mesentery was taken with the LigaSure device. The right colon was mobilized along the white line of Toldt. The duodenum was swept down. The middle colic vessels were identified and the remaining portion of the mesentery was taken at this time completing the dissection for the extended right hemicolectomy. Specimen was taken from the field and sent for permanent pathology. Again the abdomen was irrigated with another 2 L of saline. Careful attention was paid for hemostasis. NG tube placement was confirmed with manual palpation. At this time contamination was
minimal. There was no bleeding. Patient was receiving high dose
pressors at this time. Patient was now on 2 pressors, receiving large
volume fluid resuscitation, as well as blood and FFP. It was decided to
place an ABThera wound VAC and come back for a 2nd look in 24 hours to
allow for resuscitation. Blood cultures were sent at the beginning of
the case after placement of the central line. The ABThera open
abdominal VAC was placed. At the end of the case, all needle and
instrument counts were correct. No complications occurred. Specimens
were total abdominal colectomy. Case was grossly contaminated. The
patient left the operating room, intubated and in critical condition.
At the end the case all needle and instrument counts were correct.
Date of Service: 10/19/2014
PREOPERATIVE DIAGNOSIS
Septic shock, intra-abdominal sepsis, perforated colon.
POSTOPERATIVE DIAGNOSIS
Septic shock, intra-abdominal sepsis, and transmural necrotic
rectum.
PROCEDURES PERFORMED
1. Abdominal washout with removal of an ABThera abdominal VAC.
2. Total proctectomy.
3. Delayed primary abdominal wall closure and creation of an
ileostomy.
DESCRIPTION OF PROCEDURE
After consent was obtained, patient was taken to the operating room,
intubated, in critical condition. General anesthesia was administered.
A time-out taken to confirm the correct patient and procedure. Next,
the wound VAC was removed. The patient then was prepped and draped in
typical sterile fashion. The abdomen was entered. The abdomen appeared
clean. The Omni was placed, the abdominal wall was retracted, no
interloop abscesses were identified. The abdomen was irrigated with
saline and Betadine solution. Next, our attention was turned to the
deep pelvis, at which time we noticed that her stapled rectum had
worsening necrosis and perforation. There was some fecal spillage of
the pelvis. At this time, we mobilized the posterior rectum, taking
down the presacral avascular plane. The lateral stalks were identified.
They were taken with the LigaSure. The peritoneal reflection was opened,
and the rectum was dissected anteriorly to the level of the levators.
There was anterior transmural necrosis of the entire anterior wall of
the rectum with multiple areas of perforation. At this time, the Contour 55 was used to take the rectum at approximately 3 to 4 cm right
at the level of the levators. The rectum was removed and sent for
permanent pathology. The pelvis was copiously irrigated with saline and
Betadine solution and suctioned. Hemostasis was achieved with Surgicel
and pelvic packing. The remainder of the abdomen was at this time again
inspected and irrigated. An additional 10 cm of the distal ileum were
resected due to questionable viability, and a right lower quadrant
circular incision was made. The anterior rectus muscle was identified.
A muscle-splitting maneuver was done with 2 Kelly clamps. The
peritoneum was grabbed and incised. The ostomy was dilated with 2
fingers, the Babcock was passed through with placement of the staple
line in the distal ileum and delivered out and onto the skin. At this
time, careful attention was paid to make sure the ostomy was not
twisted. All packing and Surgicel were removed from the pelvis. It
appeared to be hemostatic at this time. A 10 flat JP drain was placed
in the pelvis. It was delivered out through the left lower quadrant and
sutured to the skin using a 2-0 nylon suture. Next, the abdominal
fascia was closed with #1 looped PDS. The skin was closed with staples.
The patient was transferred back to the ICU in critically ill condition.
At the end of the case, all needle and instrument counts were correct.
No complications occurred. Case was grossly contaminated. Estimated
blood loss was 200 mL.
44155???
