bpiggott
Contributor
Could someone help code the following case:
Postop Dx: Loss of abdominal domain
Name of Operation: Component separation technique w/myofascial advancement flap for delayed primary closure of abdominal wound & restoration of abdominal wall anatomy.
Description of Operation:
The vacuum assisted closure device was removed. His abdomen was
inspected, there was no evidence of fistula mesh. The skin edges
demonstrated good viability with excellent granulation tissue in the
wound. Its overall appearance was clean. It was irrigated with 5
liters of normal saline. The stomas were pink & functional. I then
made the decision to attempt a closure of his abdomen. I did perform a
further component separation technique with further elevation of his
rectus muscle & anterior fascia off of the posterior fascia. This was
carried out laterally approximately 2 to 3 cm beyond the lateral borders
of the rectus muscle, aside from adjacent to his ileostomy & mucous
fistula. This was done on both sides of his abdominal wall. I then
continued further advancement of the skin flaps involving just above the
anterior fascia. Again, this was carried out approximately 3 to 4 cm
beyond the lateral borders of his rectus muscle on both sides of his
abdominal wall. I then created four relaxing incisions of the anterior
fascia. This was approximately 3 to 4 cm beyond the lateral border of
the rectus muscle both above & below the stoma sites. This incision was
made through the returns today for & down through to the muscle. This
allowed for further advancement of the rectus flaps to be mobilized
medially for closure. There was an are of exposed bowel with no
evidence of fistula formation that was imbricated with the biologic mesh
to allow closure of this. CloSeal was used to cover this to help
prevent fistula formation in this region. I then placed four 19-French
Blade drains that lay on both left & right below the posterior fascia &
below the rectus muscle. These were exteriorized at the inferior
quadrants of his abdomen & secured to the abdominal wall with the use of
2-0 nylon. I then placed 2 additional 19-French Blake drains that were
exteriorized at the superior quadrants of his abdomen. These lay in the
skin flaps above the rectus muscle & again were secured to the abdominal
wall with the use of 2-0 nylon.
I then began a single-layer closure of his abdomen reapproximating the
fascia just medial from the rectus muscle emcompassing both the anterior
& posterior portions. This was done from the superior canthus to the
midline & from the inferior canthus to the midline with the use of #1
looped PDS with every third throw in a locking fashion. I was able to
reapproximate this under no tension. I then irrigated the subcutaneous
tissue, reapproximated the skin flaps that were created with the use of
3-0 Vicryl in a simple inverted interrupted fashion & skin clips. I
then placed a bolster incision back directly over the incision line in
the usual standard fashion, which was hooked to 150 mmHg of pressure
continuous suction with high intensity. A drape was placed over the
incision line that was fenestrated right down the middle directly over
the skin clips & this acted as a bolster incisional VAC, which was
secure & functional. Appliances were then reapproximated to his
ileostomy & mucus fistula. The general endotracheal anesthetic was
reversed, he was transferred off the operative table & to the
postanesthetic care unit in stable & satisfactory manner.
Postop Dx: Loss of abdominal domain
Name of Operation: Component separation technique w/myofascial advancement flap for delayed primary closure of abdominal wound & restoration of abdominal wall anatomy.
Description of Operation:
The vacuum assisted closure device was removed. His abdomen was
inspected, there was no evidence of fistula mesh. The skin edges
demonstrated good viability with excellent granulation tissue in the
wound. Its overall appearance was clean. It was irrigated with 5
liters of normal saline. The stomas were pink & functional. I then
made the decision to attempt a closure of his abdomen. I did perform a
further component separation technique with further elevation of his
rectus muscle & anterior fascia off of the posterior fascia. This was
carried out laterally approximately 2 to 3 cm beyond the lateral borders
of the rectus muscle, aside from adjacent to his ileostomy & mucous
fistula. This was done on both sides of his abdominal wall. I then
continued further advancement of the skin flaps involving just above the
anterior fascia. Again, this was carried out approximately 3 to 4 cm
beyond the lateral borders of his rectus muscle on both sides of his
abdominal wall. I then created four relaxing incisions of the anterior
fascia. This was approximately 3 to 4 cm beyond the lateral border of
the rectus muscle both above & below the stoma sites. This incision was
made through the returns today for & down through to the muscle. This
allowed for further advancement of the rectus flaps to be mobilized
medially for closure. There was an are of exposed bowel with no
evidence of fistula formation that was imbricated with the biologic mesh
to allow closure of this. CloSeal was used to cover this to help
prevent fistula formation in this region. I then placed four 19-French
Blade drains that lay on both left & right below the posterior fascia &
below the rectus muscle. These were exteriorized at the inferior
quadrants of his abdomen & secured to the abdominal wall with the use of
2-0 nylon. I then placed 2 additional 19-French Blake drains that were
exteriorized at the superior quadrants of his abdomen. These lay in the
skin flaps above the rectus muscle & again were secured to the abdominal
wall with the use of 2-0 nylon.
I then began a single-layer closure of his abdomen reapproximating the
fascia just medial from the rectus muscle emcompassing both the anterior
& posterior portions. This was done from the superior canthus to the
midline & from the inferior canthus to the midline with the use of #1
looped PDS with every third throw in a locking fashion. I was able to
reapproximate this under no tension. I then irrigated the subcutaneous
tissue, reapproximated the skin flaps that were created with the use of
3-0 Vicryl in a simple inverted interrupted fashion & skin clips. I
then placed a bolster incision back directly over the incision line in
the usual standard fashion, which was hooked to 150 mmHg of pressure
continuous suction with high intensity. A drape was placed over the
incision line that was fenestrated right down the middle directly over
the skin clips & this acted as a bolster incisional VAC, which was
secure & functional. Appliances were then reapproximated to his
ileostomy & mucus fistula. The general endotracheal anesthetic was
reversed, he was transferred off the operative table & to the
postanesthetic care unit in stable & satisfactory manner.