Hi,
I'm need some opinions on this case. My choice would be 11403 and 12032. Although the measurements aren't indicated on the operative report, I used the measurements on the pathology report. The length of the excision is 2.7 cm. Any input would be appreciated. Thanks
PREOPERATIVE EVALUATION
This patient has a history of a mesh implantation for hernia repair, and
a chronic wound above his umbilicus. It is my impression that this
represents a mesh infection. He is brought to the operating room for
excision of this as a prelude to fixing his larger hernia.
PREOPERATIVE DIAGNOSIS
Mesh infection.
POSTOPERATIVE DIAGNOSIS
Chronic scar.
PROCEDURE
Excision of scar.
ANESTHESIA
General endotracheal.
ESTIMATED BLOOD LOSS
Nil.
DRAINS
None.
FINDINGS
The patient did not have a mesh infection. It appeared that this was
just a chronically inflamed scar with some skin breakdown over it. I
did excise it entirely and closed it primarily.
PROCEDURE IN DETAIL
The patient was brought to the operating room and placed in supine
position on the operating table. He underwent general anesthesia per
the Anesthesia Department. He was then prepped and draped in routine
fashion to expose his abdomen whereupon an elliptical incision was then done to excise this area in its entirety. I then carried this down to a
level of healthy tissue in all directions. I did not find any evidence
of a mesh infection; no mesh was even seen.
At that point, once this was excised, I then closed the deep tissue with
2-0 Vicryl suture and the skin was closed with a subcuticular stitch of
4-0 Monocryl. Steri-Strips were applied. He was then allowed to return
to the recovery room in satisfactory condition having tolerated the
procedure well.
I'm need some opinions on this case. My choice would be 11403 and 12032. Although the measurements aren't indicated on the operative report, I used the measurements on the pathology report. The length of the excision is 2.7 cm. Any input would be appreciated. Thanks
PREOPERATIVE EVALUATION
This patient has a history of a mesh implantation for hernia repair, and
a chronic wound above his umbilicus. It is my impression that this
represents a mesh infection. He is brought to the operating room for
excision of this as a prelude to fixing his larger hernia.
PREOPERATIVE DIAGNOSIS
Mesh infection.
POSTOPERATIVE DIAGNOSIS
Chronic scar.
PROCEDURE
Excision of scar.
ANESTHESIA
General endotracheal.
ESTIMATED BLOOD LOSS
Nil.
DRAINS
None.
FINDINGS
The patient did not have a mesh infection. It appeared that this was
just a chronically inflamed scar with some skin breakdown over it. I
did excise it entirely and closed it primarily.
PROCEDURE IN DETAIL
The patient was brought to the operating room and placed in supine
position on the operating table. He underwent general anesthesia per
the Anesthesia Department. He was then prepped and draped in routine
fashion to expose his abdomen whereupon an elliptical incision was then done to excise this area in its entirety. I then carried this down to a
level of healthy tissue in all directions. I did not find any evidence
of a mesh infection; no mesh was even seen.
At that point, once this was excised, I then closed the deep tissue with
2-0 Vicryl suture and the skin was closed with a subcuticular stitch of
4-0 Monocryl. Steri-Strips were applied. He was then allowed to return
to the recovery room in satisfactory condition having tolerated the
procedure well.