# not sure how to code this



## elainehopf (Apr 14, 2014)

PROCEDURE:  Identification of the penis and spermatic cords with resection
of local lymphedematous tissue, estimated to be about 20 x 10 cm.
This is an intraoperative consultation procedure done with Plastic Surgery,


FINDINGS:
1.  Severe acquired lymphedema of the scrotum and genital skin.
2.  Severe burying of the penis.
3.  Normal-appearing glans and urethral meatus.
4.  Bilateral extremely enlarged spermatic cords with diffuse edema of
subcutaneous tissues as well as the spermatic cord.
INDICATIONS FOR PROCEDURE:  a 50-year-old man with morbid
obesity, bed bound with buried penis, recurrent scrotal abscesses and
possible hidradenitis with severe genital scrotal lymphedema and a buried
penis.  He presents today with Plastic Surgery for buried penis
reconstructive surgery with excision of lymphedematous tissue and
reconstruction of the penis with possible skin grafts and reconstruction of
the scrotum and perineum.  Our part of the procedure would be to resect the
tissue near the spermatic cords and the penile shaft and glans and
thereafter, allow Plastics to do the reconstruction.  All risks and
benefits of our procedure were discussed in detail with the patient and all
questions were answered.  Risk of surgery in general includes bleeding,
infection, cardiopulmonary event, stroke, DVT, positional injuries and even
death.  Risk for surgery, in particular includes injury to the penis,
penile shaft, testicle, scrotum, spermatic cords, need for orchiectomy,
need for further procedures, need for prolonged drainage, as well as other
adverse events not otherwise anticipated.  The patient understands these

risks and strongly wishes to proceed.  He gave us his consent.
DETAILS OF PROCEDURE:  was identified and consented
preoperatively.  He was then brought to the operating room for general
anesthesia and IV antibiotics were administered.  He was already on
preoperative heparin and antibiotics.  He also received Lovenox.
The patient was then placed in the supine position and prepped and draped
in usual fashion.  A time-out was done to confirm the correct patient and
procedure.  We also made sure to get rid of all the smegma out of the skin
well where the buried penis was housed.  This was also prepped carefully. 
Once a time-out was done to confirm the correct patient and procedure, we
made a dorsal incision through the lymphedematous tissue which involves all
of the scrotum, as well as part of the prepubic fat pad called the
escutcheon.  We cut through this area to identify and expose the glans
penis.  Once the glans penis was exposed, we placed a 2-0 Prolene suture to
help pull it out further.  The penile skin looked terrible and not viable
for saving.  We therefore cut through the penile skin and made a
circumcision incision around the penis and got rid of the penile shaft
skin.  Prior to doing this, we dissected laterally on each side of our
dorsal cut through the skin and the subcutaneous tissues.  There was a lot
of subcutaneous edema as well as large dilated vessels and veins.  These
were carefully clipped and tied.  Once this was exposed deeper, we were
able to identify 2 large spermatic cords.  Their size was consistent with
edema and hydrodistention and hydroceles.  Once we identified the spermatic
cords, we dissected down to the gubernaculum and then transected the
testicles from the gubernaculum.  This freed up the testicles.  Once the
testicles were freed, we then resected other neighboring tissue off the
penile shaft and glans and thereafter, Plastic Surgery took over for the
reconstruction.


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