# OP note: Appendectomy (no perf) but drainage of peri-appendiceal purulence



## AR2728 (Jun 26, 2012)

I'm thinking the only billable code is the appendectomy 44950.  The physician states he drained purulence from the peri-appendiceal but this was not a perforated appendix--also no micro perf noted per path.  Please view note and advise:

_Procedure: RLQ exploration, drain of peri-appendiceal purulence with appendectomy, possible micro perf

.....Dissection was then carried down to the musculofascial structures which were opened in the usual muscle splitting fashion. Properitoneal dissection was performed with peritoneum identified and opened under direct vision. Retractors were placed and omentum was retracted out with a sponge stick. The cecum and ascending colon were underneath the incision and were retracted medially with the patient rotated to the left. The right gutter was visualized with a palpably dilated appendix. There was pus along
the right gutter as well as at the base of the appendix. A swab was obtained for gram stain and culture with gram stain initial results as per above. The appendix was located in a retrocolic position. Peritoneum was carefully opened up over the appendix. Starting with the tip of the appendix, the mesoappendix was sequentially doubly clipped and divided just adjacent to the appendiceal wall. Careful dissection was done under direct vision after the peritoneum had been opened up. In this fashion, the mesoappendix was carefully divided starting at the tip and extending along the surface of the appendix back to the base of the appendix. Double ligaclips were used to maintain control of the mesoappendix in this fashion back down to the base of the appendix which was located down at the level of the anterior superior iliac spine. The cecum was able to be brought out of the wound once the mesoappendix was divided. Care was taken to evaluate the mesoappendix and it was dried before removing the appendix and also at the end of the procedure. The patient did have a significantly dilated appendix with transmural inflammation but no obvious gangrene. There was purulence around the appendix and there was a palpable
appendicolith although this was more toward the tip. The base did have significant adhesions with evidence of possible kinking. Some of these adhesions were dense. The appendix was freed up from the mesoappendix and rather than dissecting all dense adhesions from the wall of the cecum off of the appendix, the appendix was removed by firing a GIA stapler and removing a small approximately 3-4 mm rim of cecal wall around the base of the appendix. Care was taken not to involve any surrounding structures in the closure around the appendix and the cecal stump. Care was taken not to impinge on the ileocecal valve which was identified. The appendix was removed and sent to pathology. There was no evidence of gross perforation but there was evidence of possible microscopic perforation with purulence. The appendiceal closure site and staple line were
imbricated under two seromuscular 3-0 silk Z-stitches......

FINDINGS: Acute transmural appendicitis with peri-appendiceal purulence. The patient did not have a well formed abscess but did have significant purulence around the appendix. This was drained and a swab was sent to pathology. Because of the purulence, the patient was given Levaquin and Flagyl intraoperatively_.


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