Can I get some direction of where to start with these CPT codes please. Thank you all in advance.
Lynn ext 00443
PREPROCEDURE DIAGNOSIS: Stab wound to right upper quadrant of abdomen.
PROCEDURE PERFORMED: Trauma laparotomy, repair of laceration of the right
colon x2, repair of mesenteric laceration, repair of small bowel serosal
tear, appendectomy and repair of complex wound of abdominal wall.
PROCEDURE: patient taken urgently to OR due to a stab wound to the right upper quadrant. The patient was placed supine on the OR table. The abdomen was prepped and draped in sterile fashion and a midline incision was made using 15 blade in the midline, circumferentially going around the umbilicus down to the pubis. Deeper tissues were dissected using the cautery current of the Bovie. The fascia was opened sharply using the cutting current of the Bovie and the peritoneum was opened with scissors. The incision was extended cephalad and caudad by placing 2 fingers in the opening and using the cautery current of the Bovie. Retractor system was used with 4 opposing blades to allow for exposure of the abdominal
cavity. There was about 100 mL of blood encountered in the right lower quadrant. This was removed with the lap pads and there was no active bleeding of the mesentery. Began by exploring the right upper quadrant. The liver and the diaphragm were examined. There was no injury to either. Gallbladder was intact. The left diaphragm likewise was intact. The spleen was intact. The stomach was intact. Ran the small bowel from the ligament of Treitz down to the ileocecal valve. There was an injury to the mesentery of the mid small bowel right below where the mesentery meets the bowel wall. This was sutured with interrupted figure-of-eight silk suture. Hemostasis was adequate. There was no expanding hematoma. A small serosal tear was found proximal to this on the small bowel antimesenteric surface. This was closed with 3 interrupted 3-0 silk Lembert sutures. Attention was then turned to the right lower quadrant of the colon where there was a finding of a laceration to the anterior surface of the cecum and to the lateral surface of the cecum and the lateral gutter. The laceration was approximately 2 cm and this was grasped with a DeBakey forceps and closed with a running 3-0 Vicryl suture and then reinforced with a second row of 3-0 Lembert silk sutures. The laceration to the right lateral aspect of the cecum was also approximately 2 cm and this was closed in similar fashion with 3-0 running Vicryl and interrupted 3-0 silk Lembert sutures. Once complete, irrigation of the abdominal cavity was carried out with warm saline with 2 L of fluid and the fluid returned clear, and this was evacuated. The bowel was run from the ligament of Treitz all the way down to the ileocecal valve without finding any new injury to the
mesentery or small bowel. The colon was examined again from the cecum all the way down to the pelvic floor. No other additional colonic injuries were found. The area where the repair of the cecal laceration was performed was immediately next to the base of the appendix. The appendix was a coiled appendix and retrocecal. It was felt that repair would infringe upon the base of the appendix and subsequent appendicitis, decision was made to perform an incidental appendectomy as the appendix was in the field of repair. This was done in standard surgical fashion, taking the mesoappendix with the device and the base of the appendix with an stapling device. The staple line was over sewn with 3-0 interrupted silk sutures. Once this was complete, I was believed to be no other injuries, the NG tube was palpated in the stomach and the abdomen was irrigated out with 3 L of warm normal saline until the effluent was clear. Next, attention was turned towards complex repair of the abdominal wall. This was done with #1 Vicryl from the inside of the abdomen in the deep layer and then the #1 Ethibond was used for figure-of-eight closures of the fascia from externally. The wound was irrigated and dried copiously and palpated from both external and internal aspects with no gaps noted. The wound was irrigated and dried. Next, attention was turned towards closing the midline wound. The abdomen was closed using a looped #1 PDS, 1 starting cephalad, 1 starting caudad. The wound was irrigated and dried. Staples were used for the skin and a dressing was used to cover the incision.
Lynn ext 00443
PREPROCEDURE DIAGNOSIS: Stab wound to right upper quadrant of abdomen.
PROCEDURE PERFORMED: Trauma laparotomy, repair of laceration of the right
colon x2, repair of mesenteric laceration, repair of small bowel serosal
tear, appendectomy and repair of complex wound of abdominal wall.
PROCEDURE: patient taken urgently to OR due to a stab wound to the right upper quadrant. The patient was placed supine on the OR table. The abdomen was prepped and draped in sterile fashion and a midline incision was made using 15 blade in the midline, circumferentially going around the umbilicus down to the pubis. Deeper tissues were dissected using the cautery current of the Bovie. The fascia was opened sharply using the cutting current of the Bovie and the peritoneum was opened with scissors. The incision was extended cephalad and caudad by placing 2 fingers in the opening and using the cautery current of the Bovie. Retractor system was used with 4 opposing blades to allow for exposure of the abdominal
cavity. There was about 100 mL of blood encountered in the right lower quadrant. This was removed with the lap pads and there was no active bleeding of the mesentery. Began by exploring the right upper quadrant. The liver and the diaphragm were examined. There was no injury to either. Gallbladder was intact. The left diaphragm likewise was intact. The spleen was intact. The stomach was intact. Ran the small bowel from the ligament of Treitz down to the ileocecal valve. There was an injury to the mesentery of the mid small bowel right below where the mesentery meets the bowel wall. This was sutured with interrupted figure-of-eight silk suture. Hemostasis was adequate. There was no expanding hematoma. A small serosal tear was found proximal to this on the small bowel antimesenteric surface. This was closed with 3 interrupted 3-0 silk Lembert sutures. Attention was then turned to the right lower quadrant of the colon where there was a finding of a laceration to the anterior surface of the cecum and to the lateral surface of the cecum and the lateral gutter. The laceration was approximately 2 cm and this was grasped with a DeBakey forceps and closed with a running 3-0 Vicryl suture and then reinforced with a second row of 3-0 Lembert silk sutures. The laceration to the right lateral aspect of the cecum was also approximately 2 cm and this was closed in similar fashion with 3-0 running Vicryl and interrupted 3-0 silk Lembert sutures. Once complete, irrigation of the abdominal cavity was carried out with warm saline with 2 L of fluid and the fluid returned clear, and this was evacuated. The bowel was run from the ligament of Treitz all the way down to the ileocecal valve without finding any new injury to the
mesentery or small bowel. The colon was examined again from the cecum all the way down to the pelvic floor. No other additional colonic injuries were found. The area where the repair of the cecal laceration was performed was immediately next to the base of the appendix. The appendix was a coiled appendix and retrocecal. It was felt that repair would infringe upon the base of the appendix and subsequent appendicitis, decision was made to perform an incidental appendectomy as the appendix was in the field of repair. This was done in standard surgical fashion, taking the mesoappendix with the device and the base of the appendix with an stapling device. The staple line was over sewn with 3-0 interrupted silk sutures. Once this was complete, I was believed to be no other injuries, the NG tube was palpated in the stomach and the abdomen was irrigated out with 3 L of warm normal saline until the effluent was clear. Next, attention was turned towards complex repair of the abdominal wall. This was done with #1 Vicryl from the inside of the abdomen in the deep layer and then the #1 Ethibond was used for figure-of-eight closures of the fascia from externally. The wound was irrigated and dried copiously and palpated from both external and internal aspects with no gaps noted. The wound was irrigated and dried. Next, attention was turned towards closing the midline wound. The abdomen was closed using a looped #1 PDS, 1 starting cephalad, 1 starting caudad. The wound was irrigated and dried. Staples were used for the skin and a dressing was used to cover the incision.