This Year Male Question & Answer Guide (With Explanation)

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What This Question Is About

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How to Approach This Question

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Key Explanation

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Original Question

This 54-year-old male presented to the emergency department with unrelenting abdominal pain of both the lower left quadrant and the entire right side. He relates a previous history of Crohn’s disease for which he has been hospitalized multiple times. During his examination, a left midfoot ulcer that exposed the tissue of the hypodermis was identified with his diabetes. The patient indicated multiple treatments, including debridement and grafts (which failed) had been tried but the condition persists. GERD, OSA, and dyslipidemia were current conditions for which the patient was receiving treatment. The patient has COPD attributable to smoking a pack of cigarettes per day, which he continues to do despite the breathing issues. Prilosec, Crestor and Humalog (administered daily for his type 1 diabetes) are the current medications for him. An x-ray indicated the patient had extensive diverticulitis of the sigmoid colon with perforation. There was evidence of Crohn’s disease with obstruction of the right colon and the proximal transverse colon. It was decided the patient needed emergent surgery to attend to these conditions. PROCEDURES: Exploratory laparotomy, sigmoid colectomy, extended right hemicolectomy, colostomy PROCEDURE DESCRIPTION: After consent was obtained for the procedure, risks and benefits were described at length. The patient was taken to the operating room and placed supine on the operating room table. Preoperatively, the patient received 3g of IV Unasyn. The patient was placed under general endotracheal anesthesia. PAS stockings were applied to both lower extremities. The patient’s abdomen was then prepped and draped in the standard surgical fashion. A midline laparotomy incision was made from just around the umbilicus to the pubic symphysis. The midline of the fascia was divided, and the abdomen was entered. With exploration of the abdomen, extensive diverticular disease of the distal sigmoid colon was noted. First order of business was to mobilize the sigmoid colon for a sigmoid colectomy. The left ureter was identified and was far from the area of the sigmoid colon. The sigmoid colon was mobilized laterally to include the area of the diverticulitis. The sigmoid colon was mobilized down to the peritoneal reflection. The medial aspect of the sigmoid colon was also mobilized. The colon was then completely mobilized. A point of transaction was chosen at the proximal sigmoid colon. The mesentery was then taken down across the sacrum. The vessels were tied with 2-0 silk sutures. The sigmoid colon was mobilized down to the proximal rectum. Once the proximal rectum was identified, the sigmoid colon was again transected, this time using a contour Ethicon stapler with a blue load. Both the right and left ureters were identified prior to any transection of the sigmoid colon. A 3-0 Prolene suture was then tagged to either edge of the rectal staple line. The specimen was then passed off the field. The right colon was then inspected. Multiple perforations with sites of deserosalization with exposed mucosa were identified in the right colon. The right colon was mobilized by taking down the white line of Toldt all the way up to and including the hepatic flexure. The omentum was taken off the transverse colon with electrocautery. Once the colon was completely mobilized and became a medial structure, the terminal ileum was transected, this time also using a 45-mm GIA stapler with a blue load. A point of transection was chosen in the mid transverse colon just proximal to the middle colic artery where the last site of deserosalization was identified. The mid transverse colon was divided with a GIA 45-mm stapler with a blue load. The mesentery to the right colon and transverse colon were then taken down with Pean clamps and tied with 2-0 silk sutures. The specimen was then passed off the field. The abdomen was then irrigated. Hemostasis was assured. The ileocecal anastomosis was then created between the terminal ileum and the mid transverse colon. The bowels were positioned to lie alongside each other, and a side-to-side function end-end anastomosis was created using a 45-mm GIA stapler with a blue load. The enterostomies were then closed together with a running 3-0 PDS suture followed by interrupted 3-0 GIA silks in a Lembert fashion. A stitch was placed at the crotch of each of the bowel connections. A finger was palpated at the anastomosis, and it was widely patent. Mesenteric defect was then closed using 3-0 Vicryl suture in a running fashion. Attention was then turned toward formation of the end-descending colostomy. The descending colon had already been mobilized enough to make it to the anterior abdominal wall without any difficulty. A point on the anterior abdominal wall on the left-hand side just below the umbilicus was chosen for the colostomy. A small 1.5 to 2 cm circular incision was made on the anterior abdominal wall midway through the rectus muscle. The anterior fascia was divided in a cruciate fashion. The rectus muscles were split, and two fingers were palpated through the defect into the abdominal cavity. The descending colon was then grasped with an Allis clamp and passed through the defect and exteriorized. There was no tension on the colon. On the undersurface of the peritoneum, the colon was tagged with 3-0 GI silk sutures x 2. The midline fascial incision was then closed with a running #1 looped PDS x 2. The surgical incision was then irrigated with copious saline. The skin was then closed with surgical staples. The ostomy was then matured by removing the staple line and sewing the ostomy in place with 3-0 Vicryl sutures. The sutures were sewn in circumferentially. An ostomy appliance was applied. Sterile dressings were applied, and the patient was awakened from general anesthesia and transported to the recovery room in stable condition. Four days later, the patient returned to surgery to address the non-healing midfoot ulcer. This time the physician has chosen to use Miroderm, a wound matrix derived from porcine liver as the skin substitute. Once the patient was sedated, debridement of the wound was performed leaving a 4 x 6 cm area over which the Miroderm was placed. The patient was taken to PACU in stable condition. The wound was monitored over the next several days and initial healing was promising. Six days after admission, the patient was recovered enough for discharge to be followed by home health for the next three weeks, scheduled to be seen for the first time, tomorrow at 10:00 AM. Code the following: 1 point – Admitting Diagnosis: (1 code) (No POA modifier) 2 points – Principal Diagnosis: (1 code) (include POA modifier) 18 points – Secondary Diagnoses: (9 codes) (include POA modifiers) 1 point – Principal Procedure: (1 code) (PCS code) 3 points – Secondary Procedures: (3 codes) (PCS codes)

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