KNP40806
Networker
I have attached an op report below. This one has me totally stumped. I called the phy. office and they have billed it as 30118 but I just don't think that is correct. Any advise at all would be helpful. Thanks.
PREOPERATIVE DIAGNOSIS: Left nasolabial cyst/nasochoanal cyst/ mucocele.
POSTOPERATIVE DIAGNOSIS: Left nasolabial cyst/nasochoanal cyst/ mucocele.
PROCEDURES: 1. Excision of nasolabial/nasochoanal cyst/mucocele by buccal mucosal approach.
2. Mucocele closure of the left anterolateral nasal floor, length 1.2 cm.
SURGEON:
ANESTHESIA: General.
COMPLICATIONS: None.
CONDITION AFTER PROCEDURE: Stable.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating room table. General endotracheal anesthesia was induced by the anesthesia team. Next, the patient's left nasolabial cyst/nasochoanal cyst was then palpated. It was medially medial to the left nasal ala and just superior to the left buccal mucosa. It was noted to come extremely close to the nasal cavity on CT scan preoperatively.
It was decided that we would perform an upper gingival mucosal approach. The left upper gingival buccal sulcus was injected with 1% lidocaine with 1:100,000 epinephrine submucosally. After this was done, a protected needle tip Bovie electrocautery was then used to make an incision in the left upper gingival buccal sulcus. This incision was then carried down to the face of the maxilla. Next, immediately a cystic structure was identified. The cystic mass did appear to have a nice capsule and this plane of dissection was utilized. A blunt dissection with hemostat was then performed around the circumference of the mass. This then had to be freed off of the face of the maxilla and subsequently entered the region of the left anterior nasal choanae. After blunt dissection was performed around the medial aspect of the cyst, the left nasal cavity was subsequently entered using the hemostats. It seems that the cystic structure did appear to emanate from the left nasal mucosa which was noted to be anterior and lateral. This appeared to emanate just anterior to the left interior turbinate mucosa. Next, blunt dissection proceeded around the lateral aspect of the cyst. The cystic mass was subsequently punctured and copious amounts of mucopurulent secretions were seen. Culture was obtained of the mucopurulent secretions and sent to Microbiology. Next, the remainder of the cystic capsule was then subsequently resected with blunt dissection with the hemostat, bipolar electrocautery and Bovie cautery. After resection of the cyst, this left a left anterolateral nasal floor mucosal defect. This mucosal defect was then addressed through reapproximation into the left nasal floor mucosa with 4-0 Vicryl suture and 4-0 chronic suture. Reapproximation was completed successfully. The left nasal cavity was irrigated with normal saline with minimal to virtually no leak of the saline through the mucosal closure of the nasal floor. Next, the left gingivobuccal sulcus incision was then copiously irrigated with normal saline. The left gingivobuccal sulcus incision was then closed using 4-0 Monocryl suture in a running, locking fashion. After this was done, the nasal cavity and the oral cavity were suctioned of their secretions and the patient was returned to the care of the anesthesia team who awoke the patient from general anesthesia in a stable condition. The patient will be taken to the PACU for further care and treatment.
PREOPERATIVE DIAGNOSIS: Left nasolabial cyst/nasochoanal cyst/ mucocele.
POSTOPERATIVE DIAGNOSIS: Left nasolabial cyst/nasochoanal cyst/ mucocele.
PROCEDURES: 1. Excision of nasolabial/nasochoanal cyst/mucocele by buccal mucosal approach.
2. Mucocele closure of the left anterolateral nasal floor, length 1.2 cm.
SURGEON:
ANESTHESIA: General.
COMPLICATIONS: None.
CONDITION AFTER PROCEDURE: Stable.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating room table. General endotracheal anesthesia was induced by the anesthesia team. Next, the patient's left nasolabial cyst/nasochoanal cyst was then palpated. It was medially medial to the left nasal ala and just superior to the left buccal mucosa. It was noted to come extremely close to the nasal cavity on CT scan preoperatively.
It was decided that we would perform an upper gingival mucosal approach. The left upper gingival buccal sulcus was injected with 1% lidocaine with 1:100,000 epinephrine submucosally. After this was done, a protected needle tip Bovie electrocautery was then used to make an incision in the left upper gingival buccal sulcus. This incision was then carried down to the face of the maxilla. Next, immediately a cystic structure was identified. The cystic mass did appear to have a nice capsule and this plane of dissection was utilized. A blunt dissection with hemostat was then performed around the circumference of the mass. This then had to be freed off of the face of the maxilla and subsequently entered the region of the left anterior nasal choanae. After blunt dissection was performed around the medial aspect of the cyst, the left nasal cavity was subsequently entered using the hemostats. It seems that the cystic structure did appear to emanate from the left nasal mucosa which was noted to be anterior and lateral. This appeared to emanate just anterior to the left interior turbinate mucosa. Next, blunt dissection proceeded around the lateral aspect of the cyst. The cystic mass was subsequently punctured and copious amounts of mucopurulent secretions were seen. Culture was obtained of the mucopurulent secretions and sent to Microbiology. Next, the remainder of the cystic capsule was then subsequently resected with blunt dissection with the hemostat, bipolar electrocautery and Bovie cautery. After resection of the cyst, this left a left anterolateral nasal floor mucosal defect. This mucosal defect was then addressed through reapproximation into the left nasal floor mucosa with 4-0 Vicryl suture and 4-0 chronic suture. Reapproximation was completed successfully. The left nasal cavity was irrigated with normal saline with minimal to virtually no leak of the saline through the mucosal closure of the nasal floor. Next, the left gingivobuccal sulcus incision was then copiously irrigated with normal saline. The left gingivobuccal sulcus incision was then closed using 4-0 Monocryl suture in a running, locking fashion. After this was done, the nasal cavity and the oral cavity were suctioned of their secretions and the patient was returned to the care of the anesthesia team who awoke the patient from general anesthesia in a stable condition. The patient will be taken to the PACU for further care and treatment.