mfournier
Networker
Hello:
I was wondering if someone can take a peek at this op note. I was thinking 45300 but this is repair?? Unlisted? if so what do I compare it to?
Findings: Anterior rectal defect repaired with 2 layer closure, widely patent, tissues viable. No fecal spillage is noted. Negative leak test.
Indication for procedure: Intraoperative consultation to the general surgical team responded to by Dr. Siddeswarappa, and myself, with the findings of a approximately 1 cm anterior rectal defect. After assessment of the tissues and viability, intraoperative repair laparoscopically, with 2 layers of interrupted 3-0 Vicryl sutures was effected by Dr. Atkins. Rigid proctosigmoidoscopy was recommended with the repair submerged, and the proximal colon occluded, to assess the repair, and to exclude leak.
Operative technique: A rigid proctoscopy sigmoidoscope was lubricated, inserted per anus and advanced into the distal rectum. The obturator was removed. The distal rectum was insufflated with CO2 gas. The rigid proctoscopy sigmoidoscope was advanced to the repair. The tissues were well approximated. The tissues were viable. Scant solid fecal material in the rectum. I advanced beyond the repair demonstrating that the rectum was widely patent. Insufflation then continued with the repair submerged under instilled saline solution. Absolutely no extravasation of gas was noted from the repair. With the leak insufflation test now satisfied, air was removed from the colon and rectum to the extent possible, and the rigid proctoscopy sigmoidoscope was removed. A JP drain will be placed. The patient will be followed by the surgical service in consultation.
Thank you
I was wondering if someone can take a peek at this op note. I was thinking 45300 but this is repair?? Unlisted? if so what do I compare it to?
Findings: Anterior rectal defect repaired with 2 layer closure, widely patent, tissues viable. No fecal spillage is noted. Negative leak test.
Indication for procedure: Intraoperative consultation to the general surgical team responded to by Dr. Siddeswarappa, and myself, with the findings of a approximately 1 cm anterior rectal defect. After assessment of the tissues and viability, intraoperative repair laparoscopically, with 2 layers of interrupted 3-0 Vicryl sutures was effected by Dr. Atkins. Rigid proctosigmoidoscopy was recommended with the repair submerged, and the proximal colon occluded, to assess the repair, and to exclude leak.
Operative technique: A rigid proctoscopy sigmoidoscope was lubricated, inserted per anus and advanced into the distal rectum. The obturator was removed. The distal rectum was insufflated with CO2 gas. The rigid proctoscopy sigmoidoscope was advanced to the repair. The tissues were well approximated. The tissues were viable. Scant solid fecal material in the rectum. I advanced beyond the repair demonstrating that the rectum was widely patent. Insufflation then continued with the repair submerged under instilled saline solution. Absolutely no extravasation of gas was noted from the repair. With the leak insufflation test now satisfied, air was removed from the colon and rectum to the extent possible, and the rigid proctoscopy sigmoidoscope was removed. A JP drain will be placed. The patient will be followed by the surgical service in consultation.
Thank you