# 46285? 15271? Fistula surgery



## MELJNBBRB (Jun 2, 2015)

46285 ? 15271? TIA

MB,CCS,CPC




Pre-operative diagnosis: 

Recurrent Fistula in ano, transphincteric 




Post-operative diagnosis: 

Recurrent Fistula in ano, transphincteric  




Operations performed: 

1. Repair of recurrent trans-sphincteric fistula in ano with xenograft (second stage) (CPT 15271 and 15272)




Anesthesia: GETA. 




Estimated Blood loss: Less than 10 mL

IV Fluids: 600 cc

Specimen to lab: None

Indications:
is a 38 y.o. male with history of recurrent perianal fistula.  The risks and perioperative recovery related to examination under anesthesia and treatment of this fistula with xenograft were explained in detail.  The patient gave informed consent to proceed.  

SUMMARY:
The patient was taken the operating room, placed supine on the operating table, and after adequate general tracheal anesthesia was given,  was prepped and draped in usual fashion. The perianal skin was anesthetized using 0.5% Naropin local anesthetic. Anoscopy revealed the previously identified transphincteric anal fistula and previously placed setons at the 9-10 o'clock position. The tract was probed and then cleansed with hydrogen peroxide. The tract was debrided with a curette. Next, a 5 x 5 cm Matristem Surgical Matric surgical sheet was rolled into a scroll and held together with a vicryl suture. This scroll was attached to the setons that were already in place and pulled through the internal opening of the fistula in to the fistula tract. Next, a 5 x 5 cm Matristem Wound Matrix multilayer sheet was trimmed to a 3 x 3 cm circle and sutured in place with interrupted 3-0 Vicryl sutures over the internal opening of the fistula, taking care to completely cover the opening of the fistula tract internally.  Finally, 1000 mg of Matristem Micromatrix (powder) was mixed into a slurry and back filled into the fistula tract.




Hemostasis was verified. The anorectum was packed with Gelfoam soaked in 2% xylocaine jelly. He was awakened from general anesthesia after tolerating the procedure well without complications. 







































General Information






Date: 5/22/2015

Time: 1230

Status: Unposted





Location: 

Room: 07

Service: General





Patient class: Hospital Outpatient Surgery

Case classification:  

Case type:  





Trauma case?:  













Diagnosis Information






Procedure

Code





REPAIR OF ANORECTAL FISTULA WITH PLUG (EG, PORCINE SMALL INTESTINE SUBMUCOSA [SIS]) (46707) [1075617734]

46707 (CPT?) [PR REPARI ANORECTAL FISTULA W/ PLUG]






Case Diagnosis Codes





Anal fistula [565.1]






Log Diagnosis Codes





Anal fistula [565.1]


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