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Abdominoperineal resection for rectal cancer
Is CPT® 45110 the correct code for this surgery?
...patient is a pleasant 72-year-old male who was diagnosed with a very large rectal cancer approximately 7 months ago. It was a very large cancer, extending from about 3 cm above the dentate up to about 18 cm. We discussed the next stage of his therapy and I recommended a resection of his rectum with probable APR.
INTRAOPERATIVE FINDINGS: Gross perforation and contamination on the anterior aspect of the mid to low rectum into the prostate and seminal vesicle area. Significant adenopathy within the mesorectum posteriorly.
DESCRIPTION OF PROCEDURE:...We began by making an incision down through the midline from the pubis to the umbilicus and then carried it down through the fascia and into the peritoneal cavity without difficulty. A Bookwalter retracting system was setup into the place and then we gained access to the abdominal cavity. His sigmoid colon was grossly enlarged from a fair amount of impacted stool that had been unable to pass easily through the rectal cancer and I elected
to divide the colon and took the mesentery with the LigaSure and packed it up out of the way. It was obvious that the entire cancer filled up the majority of the pelvis.
We began by identifying the ureter on the left side and then dividing the left colic and superior rectal arteries, and then got into the mesorectal plane and carried it down into the pelvis. Because of the size and bulkiness of the tumor it was very difficult to get adequate access and we spent approximately 2 hours mobilizing the rectum up out of the pelvis. The lateral stalks were taken with a combination of LigaSure and the electrocautery. Anteriorly though, as we dissected
around, we quickly ran into a fair amount of cancer that had eroded through the bowel wall and extended into the peritoneal surface of the base of the bladder, as well as the prostate and seminal vesicles. There was essentially no plane in this area and as we divided down through that area
it was clear that we had gross contamination of cancer that had invaded into these planes. The bowel wall had perforated in this area and there was a hole within the anterior surface of the rectum as we divided through these areas. We were able to get down below that area. However, there was gross contamination of the pelvis with the tumor and certainly far extensive tumor that had spread throughout the area. We were able to ultimately get down below the tumor anteriorly and then the bowel was simply sectioned with electrocautery and brought out. With the specimen then removed, we irrigated out the pelvis and then I spent the rest of the time just cleaning up fragments of tumor that had been left behind until we had essentially cleared out a majority of the bulky disease. Dr. Resident then went from below and we worked on removing all the redundant mucosa within the anal canal and low rectum. Once that was cleared out that space was closed down using 2-0 and 3-0 Vicryl suture. The pelvis was irrigated out with multiple liters of warm saline and hemostasis was assured. I then mobilized up the peritoneum at the pelvic inlet, closed that and left a drain down deep in the pelvis. A hole opening was made for a colostomy in the left lower quadrant and the bowel was brought up without difficulty through there. The midline incision was then closed using No. 1 PDS suture. Staples were used to close the skin after irrigating out the subcutaneous tissues. The colostomy was matured without difficulty in the standard brook fashion. We were able to place a finger through and below the fascia without difficulty, and it was widely patent. All sponge and needle counts were correct at the end of the case.
No evidence of distant metastases was identified as the liver, spleen, stomach, and the rest of the small intestine all appeared within normal limits. The patient was awakened, extubated, and transported back to the recovery room in stable condition. All sponge and needle counts were correct at the end of the case.