AR2728
Expert
Complex preianal abscess ultrasound guide I&D ext debride fissure & nect tissue
This is more than a simple perianal abscess I&D, but I'm at a loss for exactly what procedure codes are appropriate to capture work performed. Assistance would be greatly appreciated!
Procedure:
_Ultrasound guided I&D, debridement of ext necrotic tissue, packing complex 3 o'clock abscess, unroof small 5 o'clock abscess with I&D
-Explore perianal fissue with sharp debride of necrotic tissue
-Resect thrombosed external hemorrhoidal veins.
Operative report:
The patient did have packing which was removed from the 3 o'clock opening. There was abundant liquefied necrotic tissue at this site. Opening of the anal verge revealed a 3 x 1.8 x 2 cm. deep abscessed cavity over the opening at the 3-4 o'clock position. Medially this was bordered by a single strip of 1 cm. of healthy viable tissue and a medial extension of the abscess which was 1 x 1 x 0.5 cm. This did extend down into the subcutaneous tissues. There was a fissure measuring 4 x 2 cm. wide extending from the 1 o'clock position of the anal verge along the left side of the perineum. The patient had a 1 x 0.5 cm. pustule at the 5 o'clock position. Radiology was brought in and ultrasound was obtained with only the abscessed cavity at 3 o'clock noted. There was no evidence of an abscess along the fissure on the perineum. The patient was therefore subsequently prepped and draped sterilely. Her cellulitis had decreased to 7-8 cm. and was fading over the left buttock. There was no abscessed cavity on ultrasound under the area of cellulitis which extended out from the 3 o'clock position. Once the patient was prepped and draped sterilely, swabs were obtained from the cavity and were sent for gram stain and culture. The patient did have the measured 3 x 1.8 x 2 cm. deep lesion extending out at the 3 o'clock position laterally. Fibrinous exudate was removed with pickups and scissors sharply as well as a curette. This did extend down to an underlying abscessed cavity which had inflammatory tissue but was otherwise well circumscribed. This did loop around a 1 cm. wide segment of viable tissue which was left intact. Liquefied necrotic tissue was
sharply debrided from around this. Medial to this one cm. segment of tissue was a 1 x 0.5 x 1 cm. extension of the patient's abscess. This did extend down into the rectum. On digital exam, the patient's tender nodule in the rectum was markedly decreased with inflammation decreased. The patient had the 4 x 2 cm. fissure extending out on the left side of the perineum. This did extend down and connect to the abscess itself although the fissure was more superficial. The abscess was opened up and necrotic tissue was removed with pickups, scissors and a curette. Palpation revealed no extension of the abscess underneath the fissure except for about a cm. or less at the 12 to 1 o'clock position. The patient had a 1 x 0.5 cm. pustule at the 5 o'clock position. This was unroofed and extended with a pickups and scissors. The underlying tissue was debrided with a curette where it was necrotic and dead. This was then probed and did enter into the larger 3 o'clock abscess lateral to the one cm. segment of viable tissue. After all necrotic tissue had been removed, the patient did have slow dilatation to 2-3 fingertips and insertion of a small silver anoscope. This revealed the lesion at the 3 o'clock position to extend down to the dentate line consistent with a typical perianal abscess. This had extended down around the viable tissue and into the large 3-4 o'clock abscess which in total measured approximately 4.5 x 3 x 2 cm. Necrotic tissue was gently debrided with a curette and all of the pus was drained. Swabs were obtained for gram stain and culture as above. The pustule at 5 o'clock was opened up and was drained with necrotic tissue removed. This was probed and was joined under the skin to the larger 3 o'clock abscess. The patient did have an extension to the base of her fissure on the peritoneum. There was only an extension at the site of the abscess for a cm. or less. It did not extend along the entire fissure. The wound was irrigated under pressure with antibiotic solution. After sharp debridement of all dead tissue and exploration and opening of wounds with debridement with a curette and findings as above as well as with opening up the pustule at the 5 o'clock position, the patient was noted to have some thrombosed external hemorrhoid venous structures at the posterior aspect of the 3 o'clock opening. These were dissected free and removed and sent to pathology. The wound was then irrigated under pressure with antibiotic solution. Initially a Penrose was brought up to be put in for ongoing drainage but when it was found that the Penrose had some latex in it, the patient had quarter inch nugauze packed into the opening and the tape removed followed by a large bulky dressing. Local anesthetic was injected at this site for postop pain control.
This is more than a simple perianal abscess I&D, but I'm at a loss for exactly what procedure codes are appropriate to capture work performed. Assistance would be greatly appreciated!
Procedure:
_Ultrasound guided I&D, debridement of ext necrotic tissue, packing complex 3 o'clock abscess, unroof small 5 o'clock abscess with I&D
-Explore perianal fissue with sharp debride of necrotic tissue
-Resect thrombosed external hemorrhoidal veins.
Operative report:
The patient did have packing which was removed from the 3 o'clock opening. There was abundant liquefied necrotic tissue at this site. Opening of the anal verge revealed a 3 x 1.8 x 2 cm. deep abscessed cavity over the opening at the 3-4 o'clock position. Medially this was bordered by a single strip of 1 cm. of healthy viable tissue and a medial extension of the abscess which was 1 x 1 x 0.5 cm. This did extend down into the subcutaneous tissues. There was a fissure measuring 4 x 2 cm. wide extending from the 1 o'clock position of the anal verge along the left side of the perineum. The patient had a 1 x 0.5 cm. pustule at the 5 o'clock position. Radiology was brought in and ultrasound was obtained with only the abscessed cavity at 3 o'clock noted. There was no evidence of an abscess along the fissure on the perineum. The patient was therefore subsequently prepped and draped sterilely. Her cellulitis had decreased to 7-8 cm. and was fading over the left buttock. There was no abscessed cavity on ultrasound under the area of cellulitis which extended out from the 3 o'clock position. Once the patient was prepped and draped sterilely, swabs were obtained from the cavity and were sent for gram stain and culture. The patient did have the measured 3 x 1.8 x 2 cm. deep lesion extending out at the 3 o'clock position laterally. Fibrinous exudate was removed with pickups and scissors sharply as well as a curette. This did extend down to an underlying abscessed cavity which had inflammatory tissue but was otherwise well circumscribed. This did loop around a 1 cm. wide segment of viable tissue which was left intact. Liquefied necrotic tissue was
sharply debrided from around this. Medial to this one cm. segment of tissue was a 1 x 0.5 x 1 cm. extension of the patient's abscess. This did extend down into the rectum. On digital exam, the patient's tender nodule in the rectum was markedly decreased with inflammation decreased. The patient had the 4 x 2 cm. fissure extending out on the left side of the perineum. This did extend down and connect to the abscess itself although the fissure was more superficial. The abscess was opened up and necrotic tissue was removed with pickups, scissors and a curette. Palpation revealed no extension of the abscess underneath the fissure except for about a cm. or less at the 12 to 1 o'clock position. The patient had a 1 x 0.5 cm. pustule at the 5 o'clock position. This was unroofed and extended with a pickups and scissors. The underlying tissue was debrided with a curette where it was necrotic and dead. This was then probed and did enter into the larger 3 o'clock abscess lateral to the one cm. segment of viable tissue. After all necrotic tissue had been removed, the patient did have slow dilatation to 2-3 fingertips and insertion of a small silver anoscope. This revealed the lesion at the 3 o'clock position to extend down to the dentate line consistent with a typical perianal abscess. This had extended down around the viable tissue and into the large 3-4 o'clock abscess which in total measured approximately 4.5 x 3 x 2 cm. Necrotic tissue was gently debrided with a curette and all of the pus was drained. Swabs were obtained for gram stain and culture as above. The pustule at 5 o'clock was opened up and was drained with necrotic tissue removed. This was probed and was joined under the skin to the larger 3 o'clock abscess. The patient did have an extension to the base of her fissure on the peritoneum. There was only an extension at the site of the abscess for a cm. or less. It did not extend along the entire fissure. The wound was irrigated under pressure with antibiotic solution. After sharp debridement of all dead tissue and exploration and opening of wounds with debridement with a curette and findings as above as well as with opening up the pustule at the 5 o'clock position, the patient was noted to have some thrombosed external hemorrhoid venous structures at the posterior aspect of the 3 o'clock opening. These were dissected free and removed and sent to pathology. The wound was then irrigated under pressure with antibiotic solution. Initially a Penrose was brought up to be put in for ongoing drainage but when it was found that the Penrose had some latex in it, the patient had quarter inch nugauze packed into the opening and the tape removed followed by a large bulky dressing. Local anesthetic was injected at this site for postop pain control.