Assign the appropriate ICD-9-CM and CPT codes for the following scenario:
Preoperative diagnosis: Small bowel obstruction with perforated viscus.
- Small bowel obstruction with perforated viscus
- Ischemic small bowel
- Exploratory laparotomy
- Segmental small bowel resection
- Lysis of adhesions
Specimens: Small bowel
IV fluid: 4 liters crystalloid, 3 units packed red blood cells, 500 cc Hespan
NG tube drainage: 800 cc
Patient presented with increasing abdominal pain. Initial films showed small bowel obstruction. Abdominal pain progressed in addition to some hypotension. Repeated abdominal films showed free intraperitoneal air. Emergent surgery was required. Patient was brought to the operating room and placed in the supine position. After administration of general endotracheal anesthesia, patient’s abdomen was shaved, prepped, and draped in the usual sterile fashion. A midline laparotomy incision was then made and carried down to the subcutaneous tissues using the Bovie electrocautery. The abdomen was carefully opened in the midline. The fascia and peritoneum were divided the length of the incision. Upon opening the abdomen, there was a return of a large amount of bloody peritoneal fluid with some particulate matter. Immediately visible was some obviously gangrenous small bowel. Once all the fluid had been suctioned from the abdomen, the small bowel was eviscerated. There were some omental adhesions from the patient’s previous surgery that were taken down with a combination of Bovie and blunt dissection.
Upon eviscerating the bowel, there was a long segment of small bowel which was gangrenous and this appeared to originate from an adhesive band in the right lower quadrant from patient’s previous appendectomy. This band was released. There was a significant amount of small bowel proximally that was viable and the very terminal ileum as well as the colon appeared normal. The proximal and distal lines of resection were identified and the bowel was divided in these areas using a GIA 75 stapler. The intervening mesentery to this ischemic and dead bowel was then taken down using clamps and combination of 2-0 silk as well as #0 Vicryl ties. Once this mesentery was completely taken down, the specimen was removed and set on the back table. This was later measured and found to be 150 cm. Further dissection was used to take down the remaining adhesions, identifying the patient’s upper abdominal anatomy. The stomach was visualized and appeared normal. NG tube was palpated within the stomach. The liver was visualized. There were no obvious abnormalities. The spleen also felt normal. The patient had previously undergone Whipple resection. There were some continued adhesions in the upper abdomen that were left intact. The small bowel was visualized going up to his biliary enteric anastomosis as well as his TJ anastomosis. Both of these areas appeared normal. The abdomen was copiously lavaged with approximately 6 liters of warm sterile saline and a large amount of particulate matter was removed at that time.
The small bowel was then reanastomosed in a side-to-side functional end-to-end fashion at the terminal ileum leaving the ileocecal valve intact. Measuring with an umbilical tape, there was approximately 200 cm of remaining small bowel that was viable. Once the anastomosis was completed, the mesenteric defect was closed using interrupted 3-0 silk sutures. The staple lines of the anastomosis were also imbricated using 3-0 silk sutures. At that time, it was elected to conclude the operation. The fascia was reapproximated in the midline using a running #0 PDS stitch starting inferiorly and superiorly and tied just above the umbilicus. The incision was then closed with staples. Sterile dressings were applied. The patient tolerated this reasonably well.