bda23054
Networker
I could use some assistance coding this procedure, please:
POSTOPERATIVE DIAGNOSIS
Bilateral inguinal pain, right greater than left with normal appearing anatomy on diagnostic laparoscopy.
NAME OF OPERATION
Diagnostic laparoscopy with bilateral inguinal block.
ANESTHESIA
General.
FINDINGS
Upon establishment of pneumoperitoneum and insertion of 30-degree 5-mm scope, the bilateral internal inguinal rings and direct spaces have no defects appreciated. No inflammatory changes anterior abdominal cavity and no femoral space defects appreciated. The pelvis had no free fluid, no inflammatory changes in small bowel or colon appreciated. The appendix appeared grossly normal. obstruction, again with no inflammatory changes or thickening. The gallbladder was normal in appearance. The liver was homogenous, no isolated lesions. No signs of peritonitis. Photographic evidence was obtained of no hernias appreciated bilaterally.
DESCRIPTION OF OPERATION
The procedure as well as indications, benefits and potential risks were explained to the patient. All questions were answered. With consent obtained, the patient was taken to the operative suite, placed in the supine position and general anesthesia initiated. A Foley catheter was placed. The anterior abdominal wall was prepped and draped in the usual sterile fashion. A 5-mm incision was made at the inferior edge of the umbilicus. Veress needle was inserted into the intraabdominal cavity and with negative aspiration and free flow of saline into the intra-abdominal cavity, CO2 gas was insufflated to establish pneumoperitoneum. Once adequate pneumoperitoneum was established, 0-degree 5-mm scope was used to place 5-mm port using Visiport method and no injury to the intra-abdominal structures appreciated. The scope was changed to a 30-degree 5-mm scope and the above findings were noted. The patient was placed in Trendelenburg or head-up or side-to-side position to get best visualization of the intra-abdominal cavity without inserting another port. Photographic evidence was obtained of normal anatomy and the right and left ilioinguinal nerve blocks were block with direct visualization to make sure that transillumination showed no involvement of the inferior epigastric vessels as the block was infiltrated about a centimeter medial to the ASIS bilaterally in a fan fashion. A 10 mL 40 mg Kenalog, 0.25% Bupivacaine with epinephrine used, 5 mL of this mixture placed bilaterally. The pneumoperitoneum was released and the 5-mm port was removed. The skin edges were reapproximated with a 4-0 Vicryl at the incision site and skin was cleansed with sterile saline, padded dry. Mastisol, Steri-Strips, 4 x 4 and Medipore tape was applied. The Foley catheter was gently removed. The patient was awakened and taken back to the recovery room in stable and satisfactory condition.
DISPOSITION
I will have the patient follow up with me in 2-3 weeks. He may return to work on this coming Monday. I do not see any restrictions need to be placed. I have discussed in detail with his family the normal findings. Please see the orders for complete detail.
POSTOPERATIVE DIAGNOSIS
Bilateral inguinal pain, right greater than left with normal appearing anatomy on diagnostic laparoscopy.
NAME OF OPERATION
Diagnostic laparoscopy with bilateral inguinal block.
ANESTHESIA
General.
FINDINGS
Upon establishment of pneumoperitoneum and insertion of 30-degree 5-mm scope, the bilateral internal inguinal rings and direct spaces have no defects appreciated. No inflammatory changes anterior abdominal cavity and no femoral space defects appreciated. The pelvis had no free fluid, no inflammatory changes in small bowel or colon appreciated. The appendix appeared grossly normal. obstruction, again with no inflammatory changes or thickening. The gallbladder was normal in appearance. The liver was homogenous, no isolated lesions. No signs of peritonitis. Photographic evidence was obtained of no hernias appreciated bilaterally.
DESCRIPTION OF OPERATION
The procedure as well as indications, benefits and potential risks were explained to the patient. All questions were answered. With consent obtained, the patient was taken to the operative suite, placed in the supine position and general anesthesia initiated. A Foley catheter was placed. The anterior abdominal wall was prepped and draped in the usual sterile fashion. A 5-mm incision was made at the inferior edge of the umbilicus. Veress needle was inserted into the intraabdominal cavity and with negative aspiration and free flow of saline into the intra-abdominal cavity, CO2 gas was insufflated to establish pneumoperitoneum. Once adequate pneumoperitoneum was established, 0-degree 5-mm scope was used to place 5-mm port using Visiport method and no injury to the intra-abdominal structures appreciated. The scope was changed to a 30-degree 5-mm scope and the above findings were noted. The patient was placed in Trendelenburg or head-up or side-to-side position to get best visualization of the intra-abdominal cavity without inserting another port. Photographic evidence was obtained of normal anatomy and the right and left ilioinguinal nerve blocks were block with direct visualization to make sure that transillumination showed no involvement of the inferior epigastric vessels as the block was infiltrated about a centimeter medial to the ASIS bilaterally in a fan fashion. A 10 mL 40 mg Kenalog, 0.25% Bupivacaine with epinephrine used, 5 mL of this mixture placed bilaterally. The pneumoperitoneum was released and the 5-mm port was removed. The skin edges were reapproximated with a 4-0 Vicryl at the incision site and skin was cleansed with sterile saline, padded dry. Mastisol, Steri-Strips, 4 x 4 and Medipore tape was applied. The Foley catheter was gently removed. The patient was awakened and taken back to the recovery room in stable and satisfactory condition.
DISPOSITION
I will have the patient follow up with me in 2-3 weeks. He may return to work on this coming Monday. I do not see any restrictions need to be placed. I have discussed in detail with his family the normal findings. Please see the orders for complete detail.