codedog
True Blue
I need help with this op note , thinking 48105-22 , but I don't see no debridement , maybe resction please let me know what you think , and thanks
POSTOPERATIVE DIAGNOSIS: Sepsis, necrotizing pancreatitis
PROCEDURE PERFORMED: Exploratory laparotomy, drainage of pancreas, pancreatic necrosectomy, lysis of adhesions, mobilization of splenic flexure, omentectomy
INDICATIONS FOR PROCEDURE: with hx of whipple and recent pancreatitis who presented as a transfer with peritonitis, sepsis and concern for microperforation of the descending colon. was requiring vasopressors, thus we recommend exploratory laparotomy for source control. The risks of the operation were discussed including but not limited to death, pneumonia, anastomotic leak, bleeding, need for further procedure.
PROCEDURE IN DETAIL: After the procedure was explained and all questions answered appropriately, consents were obtained. The patient was then brought back to the Operating Room, was placed in the supine position. General endotracheal anesthesia was then induced. A central line was place and a left radial a line was placed by anesthesia. A foley was inserted by myself. The patient was prepped and draped in the usual sterile fashion. A large midline incision was made and the subcutaneous tissue was divided with electrocautery down to the fascia. Above the umbilicus, the fascia was incised and the abdomen was entered safety without injury to the intraabdominal organs. The fascia was opened in its entirety and the abdomen was surveyed. There was a moderate amount of bloody/fibrinous fluid that was encountered in the anterior abdomen. This was cultured and sent out for gram stain, fungal, aerobic and anaerobic cultures. . We performed adhesiolysis taking down adhesions in the superior portion of the abdomen secondary to patient's previous Whipple procedure and current inflammatory process. The G-J anastomosis appeared intact and healthy. The stomach appeared healthy. There were extensive thin adhesions between small bowel loops which were taken down bluntly, as well as matted omentum to the transverse colon and left colon. Using the ligasure and electrocautery, the omental adhesions were removed from the colon and omentum was transected and passed off the field as specimen. There was no signs of succus or bile in the abdomen. We began mobilizing the left colon by taking down the white line of toldt. The sigmoid and descending colon all appeared healthy and viable. The splenic flexure was taken down carefully with finger fracture and electrocautery. This area was very stuck. Once the colon was medially mobilized, we encountered purulence above the remaining distal pancreas that appeared to have been walled off by the distal transverse colon. The distal pancreas was firm and edematous. Although this bowel was edematous, it appeared viable and there was no obvious perforation. The distal pancreas had a necrotic area that was expressing purulence. Any portion of loose pancreatic tissue was removed with forceps. Confident that the colon was all viable and the air was most likely secondary necrotizing pancreatitis, we decided to widely drain the area and close her abdomen. Two 19 French blake drains were laid over the distal pancreas and in the left pericolonic gutter respectfully. These were secured to the skin with 2-0 silk. The fascia was then closed with running looped #1 PDS. The subcutaneous tissue was irrigated and the skin was closed with staples. A sterile dressing was applied. The patient was transferred to the PACU on multiple pressors, awaiting placement to the SICU.
please let me know what you think and thank you
trent
POSTOPERATIVE DIAGNOSIS: Sepsis, necrotizing pancreatitis
PROCEDURE PERFORMED: Exploratory laparotomy, drainage of pancreas, pancreatic necrosectomy, lysis of adhesions, mobilization of splenic flexure, omentectomy
INDICATIONS FOR PROCEDURE: with hx of whipple and recent pancreatitis who presented as a transfer with peritonitis, sepsis and concern for microperforation of the descending colon. was requiring vasopressors, thus we recommend exploratory laparotomy for source control. The risks of the operation were discussed including but not limited to death, pneumonia, anastomotic leak, bleeding, need for further procedure.
PROCEDURE IN DETAIL: After the procedure was explained and all questions answered appropriately, consents were obtained. The patient was then brought back to the Operating Room, was placed in the supine position. General endotracheal anesthesia was then induced. A central line was place and a left radial a line was placed by anesthesia. A foley was inserted by myself. The patient was prepped and draped in the usual sterile fashion. A large midline incision was made and the subcutaneous tissue was divided with electrocautery down to the fascia. Above the umbilicus, the fascia was incised and the abdomen was entered safety without injury to the intraabdominal organs. The fascia was opened in its entirety and the abdomen was surveyed. There was a moderate amount of bloody/fibrinous fluid that was encountered in the anterior abdomen. This was cultured and sent out for gram stain, fungal, aerobic and anaerobic cultures. . We performed adhesiolysis taking down adhesions in the superior portion of the abdomen secondary to patient's previous Whipple procedure and current inflammatory process. The G-J anastomosis appeared intact and healthy. The stomach appeared healthy. There were extensive thin adhesions between small bowel loops which were taken down bluntly, as well as matted omentum to the transverse colon and left colon. Using the ligasure and electrocautery, the omental adhesions were removed from the colon and omentum was transected and passed off the field as specimen. There was no signs of succus or bile in the abdomen. We began mobilizing the left colon by taking down the white line of toldt. The sigmoid and descending colon all appeared healthy and viable. The splenic flexure was taken down carefully with finger fracture and electrocautery. This area was very stuck. Once the colon was medially mobilized, we encountered purulence above the remaining distal pancreas that appeared to have been walled off by the distal transverse colon. The distal pancreas was firm and edematous. Although this bowel was edematous, it appeared viable and there was no obvious perforation. The distal pancreas had a necrotic area that was expressing purulence. Any portion of loose pancreatic tissue was removed with forceps. Confident that the colon was all viable and the air was most likely secondary necrotizing pancreatitis, we decided to widely drain the area and close her abdomen. Two 19 French blake drains were laid over the distal pancreas and in the left pericolonic gutter respectfully. These were secured to the skin with 2-0 silk. The fascia was then closed with running looped #1 PDS. The subcutaneous tissue was irrigated and the skin was closed with staples. A sterile dressing was applied. The patient was transferred to the PACU on multiple pressors, awaiting placement to the SICU.
please let me know what you think and thank you
trent