AR2728
Expert
I know drainage of appendiceal abscess is included in 44960, but what about this?:
Drainage of localized pericecal stool collection -A portion of the op note follows:
On palpation there was an inflammatory phlegmon extending medially off of the appendix along the terminal ileum and the small bowel mesentery. Visualization revealed a significant gangrenous appendix with an inflammatory phlegmon which was walled off. On grasping this and taking down adhesions to pull the appendix out of the wound stool did come out of the wound consistent with a ruptured during dissection vs. walled off stool in the inflammatory phlegmon. Adhesions were carefully taken down digitally and the appendix was brought out of the wound. There was evidence of a perforation just distal to the base where the stool appeared to be leaking from. This was controlled with the dilated appendix decompressed, collected and lap pads to keep this separate from the abdomen and the wound. A swab was obtained from this region for culture. The patient did have a
thickened distended, gangrenous appendix with significant swelling of the cecum which was thickened and edematous but without evidence of mass. Virtual colonoscopy had been negativeone year ago. The terminal ileum was also inflamed and edematous as was the mesentery, the mesoappendix and surrounding omentum involved in the patient's inflammatory phlegmon. The appendix was brought up and mesoappendix was divided between double silk ties dividing this along its course back down to its base. There was further thickened fat around the base with significant thickening. This involved the terminal ileal fat pad as well as portion of mesoappendix and the small bowel mesentery. On taking this down with gentle dissection the fat pad did pull away and a large appendicolith fell out where it had eroded through the base of the appendix right at the base. This was retrieved and sent to pathology. The mesoappendix was freed up and divided
between double silk ties and the appendix freed up down to its base. There was a large opening approximately 3 mm. distal to the base. Due to the edematous tissue in the cecum a staple closure was not easily viable. Therefore a right ankle clamp was placed around the small nubbin of nongangrenous appendiceal stump just proximal to where the appendicolith had eroded through. This was placed around the cecal wall at the base of the appendix. This was then tied off with a chromic suture and the appendix divided and sent to pathology. The area of the tied off appendiceal stump was then inverted beneath several 3-0 silk Z type sutures embrocating the closure underneath a seromuscular layer. This was closed in two layers in this fashion. The sutures were left in place and a portion of the omentum that was extending down into the right lateral pelvis was freed up and
was brought over the closure and tied down in the form of a Graham patch. Care was taken not to impinge on the ileocecal valve. With the closure, therefore performed and intact and buttressed with a Graham patch the right lower quadrant, the right side of the pelvis and the right gutter was irrigated thoroughly with copious amounts of saline with effluent returning clear. The ileocecal valve was identified and the small bowel was run proximally for about 120 cm. There was a diverticulum which did not appear to be a Meckle's diverticulum with no feeding blood vessel to it. This simply appeared to be an unremarkable jejunal diverticulum without scarring or inflammation and was simply left in place. There was thickening and inflammation of the very distal ileum where the appendix has been walled off with omentum fat. The wall of the cecum and small bowel mesentery. The cecum itself was rubbery and inflamed but no evidence of tumorous mass. Evaluation of the appendiceal stump revealed no evidence of mass with simply an eroded large appendicolith. The wound was then irrigated and the right lower quadrant at the site of appendix, right gutter and in the right side of the pelvis with antibiotic solution with effluent returning clear.
Drainage of localized pericecal stool collection -A portion of the op note follows:
On palpation there was an inflammatory phlegmon extending medially off of the appendix along the terminal ileum and the small bowel mesentery. Visualization revealed a significant gangrenous appendix with an inflammatory phlegmon which was walled off. On grasping this and taking down adhesions to pull the appendix out of the wound stool did come out of the wound consistent with a ruptured during dissection vs. walled off stool in the inflammatory phlegmon. Adhesions were carefully taken down digitally and the appendix was brought out of the wound. There was evidence of a perforation just distal to the base where the stool appeared to be leaking from. This was controlled with the dilated appendix decompressed, collected and lap pads to keep this separate from the abdomen and the wound. A swab was obtained from this region for culture. The patient did have a
thickened distended, gangrenous appendix with significant swelling of the cecum which was thickened and edematous but without evidence of mass. Virtual colonoscopy had been negativeone year ago. The terminal ileum was also inflamed and edematous as was the mesentery, the mesoappendix and surrounding omentum involved in the patient's inflammatory phlegmon. The appendix was brought up and mesoappendix was divided between double silk ties dividing this along its course back down to its base. There was further thickened fat around the base with significant thickening. This involved the terminal ileal fat pad as well as portion of mesoappendix and the small bowel mesentery. On taking this down with gentle dissection the fat pad did pull away and a large appendicolith fell out where it had eroded through the base of the appendix right at the base. This was retrieved and sent to pathology. The mesoappendix was freed up and divided
between double silk ties and the appendix freed up down to its base. There was a large opening approximately 3 mm. distal to the base. Due to the edematous tissue in the cecum a staple closure was not easily viable. Therefore a right ankle clamp was placed around the small nubbin of nongangrenous appendiceal stump just proximal to where the appendicolith had eroded through. This was placed around the cecal wall at the base of the appendix. This was then tied off with a chromic suture and the appendix divided and sent to pathology. The area of the tied off appendiceal stump was then inverted beneath several 3-0 silk Z type sutures embrocating the closure underneath a seromuscular layer. This was closed in two layers in this fashion. The sutures were left in place and a portion of the omentum that was extending down into the right lateral pelvis was freed up and
was brought over the closure and tied down in the form of a Graham patch. Care was taken not to impinge on the ileocecal valve. With the closure, therefore performed and intact and buttressed with a Graham patch the right lower quadrant, the right side of the pelvis and the right gutter was irrigated thoroughly with copious amounts of saline with effluent returning clear. The ileocecal valve was identified and the small bowel was run proximally for about 120 cm. There was a diverticulum which did not appear to be a Meckle's diverticulum with no feeding blood vessel to it. This simply appeared to be an unremarkable jejunal diverticulum without scarring or inflammation and was simply left in place. There was thickening and inflammation of the very distal ileum where the appendix has been walled off with omentum fat. The wall of the cecum and small bowel mesentery. The cecum itself was rubbery and inflamed but no evidence of tumorous mass. Evaluation of the appendiceal stump revealed no evidence of mass with simply an eroded large appendicolith. The wound was then irrigated and the right lower quadrant at the site of appendix, right gutter and in the right side of the pelvis with antibiotic solution with effluent returning clear.