aprilnc
New
I could use a little help, please. I recieved this following op note from my MD and was unsure of how to code the procedures. Any help is greatly appreciated.
Operative Procedure
Exploratory Laparotomy, extensive lysis of adhesions and release of incarcerated ventral hernia, and division of multiple muscular and fascial left lateral abdominal wall openings.
Findings
At exploration, the patient had an essentially attenuated large left abdomial wall muscle and fascia secondary to an extremely large hernia with multiple tracking subcutaneous tracts. There were several hernias from the fascial aspect in the left lateral abdominal wall, some of which stemmed from the midline and some of which stemmed from previous colostomy site. There were several tracts in the subcutaneous tissue, and after further inspection and release of multiple dense adhesions and mobilization of the bowel, it was felt that this could not be repaired, and subsequently I felt it best to leave the patient with a large ventral hernia but to devide the muscular facial areas between the hernias in order to not allow incarceration and/or strangulation in the future. Subsequently, multiple areas were opened up in order to make a completely free space in the left lateral abdomen. This was done with a LigaSure and electrocautery for hemostasis. Following opening up the entire left later abdominal wall, the abdominal wall fascia was then closed in the anterior midline as best as possible with a running looped PDS and a wound VAC was placed. The patient tolerated the procedure well.
Thank you in advance for any help you can provide.
Operative Procedure
Exploratory Laparotomy, extensive lysis of adhesions and release of incarcerated ventral hernia, and division of multiple muscular and fascial left lateral abdominal wall openings.
Findings
At exploration, the patient had an essentially attenuated large left abdomial wall muscle and fascia secondary to an extremely large hernia with multiple tracking subcutaneous tracts. There were several hernias from the fascial aspect in the left lateral abdominal wall, some of which stemmed from the midline and some of which stemmed from previous colostomy site. There were several tracts in the subcutaneous tissue, and after further inspection and release of multiple dense adhesions and mobilization of the bowel, it was felt that this could not be repaired, and subsequently I felt it best to leave the patient with a large ventral hernia but to devide the muscular facial areas between the hernias in order to not allow incarceration and/or strangulation in the future. Subsequently, multiple areas were opened up in order to make a completely free space in the left lateral abdomen. This was done with a LigaSure and electrocautery for hemostasis. Following opening up the entire left later abdominal wall, the abdominal wall fascia was then closed in the anterior midline as best as possible with a running looped PDS and a wound VAC was placed. The patient tolerated the procedure well.
Thank you in advance for any help you can provide.