Operative Report | Converted Laparoscopic

Oct 9, 2019 | Uncategorized

Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn– Click Here to Submit Redacted Surgery Case Study –nnDATE OF PROCEDURE: October 2017nPREOPERATIVE DIAGNOSIS: Acute diverticulitis.nPOSTOPERATIVE DIAGNOSIS: Acute diverticulitis with obstruction.nESTIMATED BLOOD LOSS: Minimal.nCOMPLICATIONS: No immediate complications.nnDESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and laid in supine position. General endotracheal anesthesia was induced. Pre-op antibiotics were given. An infraumbilical incision was made. This was carried down through subcutaneous tissue and fat until I arrived at the fascia. Incision was made in the fascia. A 10-12 port was inserted into the abdomen. The abdomen was insufflated with CO2. I placed 3 other 8 nun ports. The robot was then docked. I then proceeded with an extensive lysis of adhesions. I dissected out the sigmoid colon. There was a large amount of chronic inflammation. I dissected down to just above the rectum and I dissected up toward the descending left colon. Once I had completely dissected and freed out the majority of the diseased portion of the sigmoid, I used the robotic stapling device and I fired this proximal and distal to the diseased portion of the colon. An incision was made in the suprapubic area. The colon was removed out of the abdomen. I checked to make sure I had adequate hemostasis. I then proceeded to dissect down the descending colon attachments so I could bring this down toward the remaining Hartmann pouch. I dissected as much as I could of the lateral peritoneal reflection. However, I did not have adequate length in order to provide a tension-free anastomosis. Therefore, I had to convert to an open procedure, making a lower abdominal incision. I was then able to dissect out the remaining lateral peritoneal reflections up to the splenic flexure. This gave me adequate length in order to bring down my descending colon for my anastomosis. I used a pursestring device on the very end of the left descending colon. I placed an anvil after sizing the anus and rectum with the EEA. The EEA device was then placed from the anus into the rectum. The pin was fired just anterior to the staple line. The anvil was placed down with the descending colon. The EEA was fired. I did reinforce portions of my circular anastomosis with 3-0 silk suture. I checked to make sure that I had adequate complete donuts, which I did. I irrigated out the abdomen. I approximated and closed the fascia using a running #1 PDS suture. I irrigated out the subcutaneous tissue. I approximated and closed all incisions with staples. The patient tolerated the procedure well.nn10/2017 – Lab Report: SURGICAL PATHOLOGY EXAMnnNote: All result statuses are Final unless otherwise noted.nnTests: (1) SURGICAL PATHOLOGY EXAM (SURG)nnSpecimens: A) – Large Intestine, Sigmoid ColonnB) – Large Intestine, Sigmoid Colon, ANASTOMOTIC RINGSnnFinal DiagnosisnColon, sigmoid, segmental resection:nnDiverticular disease complicated by acute diverticulitis, diverticular abscess, and acute serositis with adhesion formationnNo dysplasia or malignancynnColon, sigmoid, anastomotic rings, resection:nnTwo fragments of colon wall without significant pathologic abnormalitiesnNo dysplasia, acute inflammation or malignancynnClinical Information Diverticulitis with abscessnnGross DescriptionnReceived in formalin and labeled with the patient’s name and medical record number are two specimens.nnReceived is a portion of the sigmoid colon measuring 20.5 cm in length and varying from 2.0 to 4.0 cm in diameter. Serosa coating the segment of bowel is showing focally yellowish discoloration, fibrin adhesions and hemorrhage. Definitive perforation site is not grossly identified.nThe specimen is opened and reveals numerous diverticular openings.nLocated in the center of the specimen is an area of marked stenosis with only about l cm of open luminal diameter. Sectioning through the segment reveals numerous diverticular openings. Several of the diverticular openings extend to close proximity of free serosal surface that is coated with fibrin and hemorrhage. Definitive microabscesses are absent.nMultiple representative sections in total of five.nnReceived are two anastomotic rings measuring 2.5 x 2.2 x 1.7 cm and 1.4 x 2.0 x 1.5 cm. Representative section of each submitted in two.nnMicroscopic DescriptionnA, B. Microscopically examined.