Medical HCPCS Procedure Documentation

Name of the Procedure:

Common Names: Right Hemicolectomy, Ileocecal Resection
Technical Terms: Right Colon Resection, Ileocecal Valve Resection

Summary

A right hemicolectomy or ileocecal resection is a surgical procedure that involves removing the right portion of the colon along with the ileocecal valve, which connects the small intestine to the large intestine. This surgery is typically performed to remove diseased or cancerous sections of the colon and ensure healthy bowel function.

Purpose

Medical Conditions Addressed:

• Colon cancer in the right colon
• Crohn's disease affecting the ileocecal junction
• Large polyps or growths in the right colon
• Severe bleeding from the right colon ##### Goals:
• Removal of diseased or cancerous tissue
• Restoration of normal bowel function
• Prevention of further health complications related to the affected area

Indications

Symptoms or Conditions:

• Persistent right lower abdominal pain
• Unexplained weight loss
• Blood in the stool
• Chronic diarrhea or constipation
• Diagnosed colon cancer or pre-cancerous lesions in the right colon ##### Patient Criteria:
• Confirmed diagnosis requiring surgical intervention
• Adequate physical health to withstand surgery

Preparation

• Fasting: Typically, patients need to fast for 8-12 hours prior to surgery.
• Medications: May require adjustments (e.g., blood thinners might need to be stopped).
• Diagnostic Tests: Blood tests, imaging studies like a CT scan or MRI, and a colonoscopy may be required prior.

Procedure Description

1. Anesthesia: The patient is given general anesthesia.
2. Incision: An incision is made in the abdomen to access the colon.
3. Resection: The affected section of the colon along with neighboring lymph nodes is removed. The ileum is then connected to the remaining portion of the colon.
4. Closure: The incisions are closed with sutures or staples.
5. Inspection: The area is inspected to ensure there is no bleeding or leakage.

Tools and Equipment:

• Surgical scalpel and forceps
• Stapling devices
• Laparoscopic instruments (in minimally invasive cases)

Duration

Typically, the procedure lasts between 2 to 4 hours.

Setting

This procedure is performed in a hospital operating room.

Personnel

• Surgeon: Performs the resection.
• Nurse: Assists in the surgery and monitors the patient.
• Anesthesiologist: Administers anesthesia and monitors its effects.

Risks and Complications

Common Risks:

• Infection at the incision site
• Bleeding ##### Rare Risks:
• Bowel leakage at the resection site
• Blood clots
• Injury to nearby organs

Benefits

• Removal of diseased or cancerous tissue
• Reduced symptoms and improved quality of life ##### Realization Timeline:
• Benefits often realized within a few weeks post-surgery as the patient recovers.

Recovery

Post-Procedure Care:

• Pain management with prescribed medications
• Gradual reintroduction of food and fluid intake
• Avoiding heavy lifting for several weeks ##### Recovery Time:
• Generally, 4 to 6 weeks, with follow-up appointments to monitor healing.

Alternatives

Other Options:

• Medications for inflammation (e.g., in Crohn’s disease)
• Endoscopic removal of polyps (for non-cancerous growths)
• Observation and regular monitoring ##### Pros and Cons:
• Medications: Non-invasive but may not be sufficient for all cases.
• Endoscopic Removal: Minimally invasive but only for certain conditions.
• Observation: No immediate intervention but risk of disease progression.

Patient Experience

During Procedure:

• The patient will be under general anesthesia, meaning no pain or awareness during the surgery. ##### Post-Procedure:
• Soreness and discomfort at the incision site
• Potential for temporary dietary restrictions ##### Pain Management:
• Pain relievers as prescribed
• Techniques such as deep breathing exercises to manage discomfort

This documentation provides a comprehensive overview of the right hemicolectomy or ileocecal resection procedure, ensuring that patients and healthcare providers have a clear understanding of what to expect before, during, and after the surgery.