codedog
True Blue
This was booked a a fistula, but no fistula found , but a benign polyp was found , should this be 45171 -excision of rectal tumor ?any suggestions please let me know
PREOPERATIVE DIAGNOSIS: Possible perianal fistula.
POSTOPERATIVE DIAGNOSIS: Left distal rectal mass.
PROCEDURES PERFORMED: Examination under anesthesia and biopsy of left distal rectal mass.
ANESTHESIOLOGIST:
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: This is a 62-year-old who was about a month after sigmoidectomy for a colovesicular fistula, has complaint of daily perianal discharge, which had been present before surgery retrospectively. On exam, the patient appeared that she may have the external opening of a fistula. She is consented for exam, possible fistulotomy. On exam in the preoperative holding area, the patient had significant amount of stool smeared around her anus. There was nothing coming from her vagina. Physical exam of her vagina intraoperatively revealed no wall masses and no discharge from the vagina.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in a prone Jackknife position. The perianal region was prepped and draped in a sterile fashion. 10 cc of 1% lidocaine with epinephrine was injected as a local anesthesia. The anus was gently dilated up to three fingerbreadths. On external inspection, there were no abnormalities. Hill Ferguson retractor was inserted into the anus. There were some minimal internal hemorrhoids. The mucosa was pink and healthy circumferentially. There was no sign of a fistula on external or internal exam. There was a 1 x 0.5 cm benign-appearing polyp of the left distal rectum just proximal to the anal verge. This was excised and sent for specimen. Hemostasis was achieved easily with electrocautery. No other abnormalities were identified despite an extensive search. The patient had not been bowel prepped. There was some proximal pasty stool and rigid proctoscopy to examine the anastomosis would not be possible. The patient tolerated the procedure well.
PREOPERATIVE DIAGNOSIS: Possible perianal fistula.
POSTOPERATIVE DIAGNOSIS: Left distal rectal mass.
PROCEDURES PERFORMED: Examination under anesthesia and biopsy of left distal rectal mass.
ANESTHESIOLOGIST:
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: This is a 62-year-old who was about a month after sigmoidectomy for a colovesicular fistula, has complaint of daily perianal discharge, which had been present before surgery retrospectively. On exam, the patient appeared that she may have the external opening of a fistula. She is consented for exam, possible fistulotomy. On exam in the preoperative holding area, the patient had significant amount of stool smeared around her anus. There was nothing coming from her vagina. Physical exam of her vagina intraoperatively revealed no wall masses and no discharge from the vagina.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in a prone Jackknife position. The perianal region was prepped and draped in a sterile fashion. 10 cc of 1% lidocaine with epinephrine was injected as a local anesthesia. The anus was gently dilated up to three fingerbreadths. On external inspection, there were no abnormalities. Hill Ferguson retractor was inserted into the anus. There were some minimal internal hemorrhoids. The mucosa was pink and healthy circumferentially. There was no sign of a fistula on external or internal exam. There was a 1 x 0.5 cm benign-appearing polyp of the left distal rectum just proximal to the anal verge. This was excised and sent for specimen. Hemostasis was achieved easily with electrocautery. No other abnormalities were identified despite an extensive search. The patient had not been bowel prepped. There was some proximal pasty stool and rigid proctoscopy to examine the anastomosis would not be possible. The patient tolerated the procedure well.
