Documentation Dissection

Operative Report

PREOPERATIVE DIAGNSOSIS: Ischemic bowel with portal venous gas.

POSTOPERATIVE DIAGNOSIS: Perforated appendicitis with diffuse peritonitis |1|.

PROCEDURES: 1. Exploratory laparotomy |2|. 2. Appendectomy |2|.

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS: This is a 73-year-old gentleman who presented to the hospital with a markedly distended abdomen and three-day history of severe abdominal pain, nausea and vomiting. He also has a history of coronary artery disease and is post coronary stenting five years ago, but is not currently on Plavix. He had a significant leukocytosis with lactate of 3.5 and a CT scan preoperatively showing portal venous gas, diffuse pneumatosis of the small bowel and multiple loops of dilated bowel. We consented him to bring him to the operating room for an exploratory laparotomy with the concern that he had ischemic bowel secondary to his atherosclerotic disease.

FINDINGS: 1. Indurated, perforated appendicitis |3|. 2. Mildly dilated jejunum with no ischemic changes and inflammatory rind. There are some areas ofmild bowel wall hemorrhage, however, the bowel appeared to be intact and viable |4|. 3. The patient was irrigated with copious amounts of normal saline and his skin was left open.

DESCRIPTION OF PROCEDURE: After obtaining an informed consent from the family, the patient was brought to the operating room and placed on the table in supine position. He was prepared by anesthesia by first placing arterial line and appropriate IV access. After the induction of anesthesia, which was without complication, he was then prepped and draped in the usual sterile fashion using chlorhexidine. We made a mid abdominal incision just above the umbilicus using a knife and electrocautery. We carried dissection through the subcutaneous fat down to the level of the fascia. We divided the fascia, found the peritoneum, which we also opened with electrocautery. We proceeded to open the abdomen the length of our incision and explored the abdomen |5|. We did not have appropriate visualization and went ahead and extended our incision to below the level of the umbilicus. We eviscerated the patient and examined his bowel in its entirety. He has some mild inflammatory changes to his jejunum and some areas of mild bowel wall hemorrhage. However, the small bowel looked viable. We followed the small bowel proximally and found the ligament of Treitz. All of the bowel here was appropriate. We then followed the bowel distally until we found the cecum. During this process we encountered large amounts of purulent material, which we suctioned for visualization |6|. We then saw an indurated inflamed perforated appendix |7|. We were able to see the ileum directly into the cecum and this junction appeared normal. The remainder of the cecum also appeared normal. We then proceeded to mobilize the cecum bluntly. Once we were able to pull the appendix into the center portion of the field, we proceeded to perform our appendectomy.

We put a large clamp across the base of the appendix and divided it above the clamp using a knife. We then proceeded to put a 2-0 Vicryl stick tie around the base of the appendix. 3-0 Vicryl sutures were then used to dunk the appendix to imbricate over the top of the appendix after remaining mucosa had been cauterized |8|. To further secure this, an 0 Vicryl suture was passed over the stump using a figure-of-eight fashion twice. We found our appendectomy to be complete and well secured. During that above-mentioned process we also ligated the appendiceal artery by tying it both proximally and distally with 2-0 Vicryl ties and dividing it with scissors. We then proceeded to re-inspect the abdomen we found no other identifiable pathology. The abdomen was then irrigated with 8 liters of normal saline. Once our fluid was cleaned, we proceeded to close the abdomen. We closed our fascia using 1 PDS in a running fashion meeting in the middle from the top and the bottom. We took approximately 1 cm deep bites entrapped with 1 cm purse stitch. This was done without complication. We left the skin open and placed a moist dressing in

1 the subcutaneous tissue. Sterile dressings were then applied. The patient was then taken to the SICU intubated. He will remain for broad-spectrum antibiotics while he awaits resolution of his ileus.

There were no complications during this procedure. The patient received approximately 2 liters of albumin and 2 liters of crystal- loid intraoperatively.

______

|1| Diagnosis is perforated appendicitis with peritonits.

|2| The procedures performed are exploratory laparotomy and appendectomy.

|3| Confirms Postoperative diagnosis.

|4| Since bowel is intact and no treatment provided, this wouldn’t be an additional diagnosis.

|5| Exploratory laparotomy is designated in as a separate procedure. A separate procedure should not be report in addition to the code for the total procedure of which it is considered an integral component.

|6| Indication of peritonitis.

|7| Confirmation of perforated appendix with peritonitis.

|8| Appendectomy performed.

______

What are the CPT® and ICD-10-CM codes reported?

CPT® Code: 44960

ICD-10-CM Code: K35.2

Rationale:

CPT®: Report 44960 for ruptured appendix with abscess or generalized peritonitis. The exploratory laparotomy is designated as a separate procedure and an integral component of the appendectomy. It would not be coded in addition to the appendectomy. Look in the CPT Index for Appendectomy/Appendix Excision for codes choices 44950, 44955, 44960. Code 44960 is Appendectomy; for ruptured appendix with abscess or generalized peritonitis and is the correct code.

ICD-10-CM: Only one diagnosis is reported. The mild bowel wall hemorrhage wasn’t significant for treatment and had no impact on the procedure. In the ICD-10-CM Alphabetic Index locate Appendicitis/with/peritonitis/generalized (with perforation or rupture) K35.2. The Tabular List verifies K35.2 is Appendicitis (acute) with generalized (diffuse) peritonitis following rupture or perforation of appendix.

2