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A continent ileostomy, commonly known as the Kock procedure, is a surgical intervention designed for patients who have undergone a coloproctectomy, which is the removal of the colon and rectum. This procedure creates an internal pouch that serves as a reservoir for stool, allowing for the collection of fecal matter without the need for external stoma bags or devices. The procedure involves making a midline incision in the abdomen to access the ileum, which is the final section of the small intestine. A specific segment of the ileum, typically between 45 to 60 centimeters, is mobilized and folded back on itself. This segment is then opened and sutured together to form a pouch, which can be shaped like an 'S' or 'J'. The distal segment of the ileum, approximately 15 centimeters long, is utilized to create an ileal valve, which is essential for controlling the flow of stool from the reservoir. To facilitate this, electrocautery is employed to scarify the 15-centimeter segment of ileum located just distal to the newly formed reservoir. The adjacent mesentery, which is the tissue that attaches the intestines to the abdominal wall, is excised to allow for proper positioning of the bowel. The scarified segment is then telescoped into the reservoir, a process known as intussusception, which helps to form the ileal valve. This telescoped portion is secured to the pouch using staples or sutures, and the pouch is subsequently closed with sutures. Additionally, a separate incision is made, typically in the right lower quadrant of the abdomen, through which the distal end of the ileum is brought to the surface and sutured flush with the skin, creating a stoma. The ileal pouch is then attached to the abdominal wall, and a large diameter plastic tube is inserted into the stoma. This tube remains in place for several weeks and is occluded for progressively longer periods to promote the expansion of the pouch. Once the patient is able to tolerate occlusion for up to eight hours, the tube is removed. Following this, the patient is instructed to intubate the pouch through the ileal stoma several times a day to facilitate the drainage of fecal matter from the reservoir.
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The continent ileostomy (Kock procedure) is indicated for patients who have undergone a coloproctectomy. This procedure is typically performed in cases where there is a need for an alternative method of stool collection due to the absence of the colon and rectum. The indications may include:
The Kock procedure involves several detailed steps to create a continent ileostomy. The procedure begins with the patient under general anesthesia, followed by a midline abdominal incision to access the ileum.
After the Kock procedure, patients will require careful monitoring and follow-up care. Post-operative care includes managing the stoma and ensuring the ileal pouch functions correctly. Patients are typically educated on how to intubate the pouch to facilitate drainage and are advised on dietary modifications to support pouch health. Recovery may involve a gradual return to normal activities, with specific attention to any signs of complications such as infection or pouch dysfunction. Regular follow-up appointments are essential to assess the pouch's function and the patient's overall health status.
| Short Descr | DEVISE BOWEL POUCH | Medium Descr | CONTINENT ILEOSTOMY KOCK PROCEDURE SPX | Long Descr | Continent ileostomy (Kock procedure) (separate procedure) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 73 - Ileostomy and other enterostomy |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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