bda23054
Networker
Could use some insight as to how to code this procedure...
FINDINGS: This patient, on x-ray today, does have free air suspected perforated viscus secondary to an EGD or colonoscopy on 07/20/12. Upon establishment of midline incision the patient was noted from surgical changes in the past, she does not have umbilicus. She does have some interrupted wire suture of the abdominal wall that were removed in the midline. The evaluation of the colon showed a perforation about 1 cm size area in the mid sigmoid colon. There is some gross spillage of stool. There are no other perforations or thickened areas appreciated, no other injuries noted. The small bowel did have a significant amount of adhesions consistent with her past surgical history of some kind of bypass surgery in the past, however, no surgical changes of the gastric lumen were noted on the EGD 72 hours ago and I did not see any evidence of this today, however, I did not run the entire length of the small bowel leaving some adhesions in place in the midabdomen. The colon otherwise was normal. The right upper quadrant showed adhesions that once they were taken down no injury to the proximal small bowel or gastric lumen appreciated. Given the perforation found in the sigmoid colon I did not pursue any further investigation of the upper abdomen. The liver was homogeneous without any isolated lesions. There did appear to be small ventral hernia to the right side of the abdominal wall as well. There was a significant amount of anterior abdominal wall adhesions appreciated that were easily taken down on opening of the laparotomy. There was noted some inflammatory changes appreciated to the omentum and the thickening of the peritoneum and the pelvis consistent with infection peritonitis type changes.
DESCRIPTION OF OPERATION
The procedure, as well as indications, benefits, 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, art line and central line were placed per anesthesia. The patient was then placed in the low lithotomy position with legs in stirrups in case we need to make a low anastomosis. The anterior abdominal wall was prepped and draped in the usual sterile fashion after a Foley catheter was placed. Ioban was placed over the abdominal wall.
A midline incision was made with a 10-blade scalpel in the upper abdomen midline. Electrocautery was used to carry dissection down to the fascia. The fascia was elevated and carefully incised with Metzenbaum scissors, With posterior protection the midline fascia was opened with electrocautery. As the wire sutures were encountered they were removed. The incision length was extended cephalad and caudad to get adequate visualization of the pelvis. The Bookwalter self-retaining retractor was placed, a bladder blade was placed and walls were retracted to visualize the colon. Some more omental adhesions and small bowel adhesions to the anterior abdominal wall were taken down, taking care not to injure or cause any full-thickness injury to the small bowel. The above findings were noted. The pelvis was irrigated with a liter of sterile saline to remove gross debris. The perforation had some soft stool leaking from it. At this point I close this perforation with interrupted Lembert 2-0 and 3-0 silk sutures to oversew this perforation in a single layer. Closure of the actual leak was then followed by further irrigation and exploration of the rest of the abdomen and takedown of anterior abdominal wall adhesions to visualize the liver and left upper quadrant, as well as the stomach and anterior structure of the duodenum. With no other significant pathology appreciated, and given the patient's recent history, I did not takedown all of the mid abdomen adhesions given her critical state and certainly did not resect the sigmoid colon at this point with her acidotic, hypothermic, hypotensive. The patient's abdomen was then irrigated with copious amounts of warm saline and no active bleeding was appreciated. The Abthera wound dressing was then cut to fit and draped over the intra-abdominal contents posterior to the peritoneal and the midline was loosely approximated with the blue sponge with gapping about 6 cm. The occlusive dressing was applied and negative pressure to the Abthera V.A.C. was then applied. The patient's Foley catheter was then placed. She was going to remain on the ventilator and she was taken to the Intensive Care Unit in stable and guarded condition. We will continue postoperative antibiotic therapy. All sponge and instrument counts were correct
DISPOSITION
We will plan to take the patient back in 24 to 72 hours for a second look procedure most likely about 48 hours from now when she is more stable to potentially close the abdominal wall. I will also have Dr. McKibben follow along for medical management and assistance in critical care management during her stay in the Intensive Care Unit. Please see the orders for complete detail.
FINDINGS: This patient, on x-ray today, does have free air suspected perforated viscus secondary to an EGD or colonoscopy on 07/20/12. Upon establishment of midline incision the patient was noted from surgical changes in the past, she does not have umbilicus. She does have some interrupted wire suture of the abdominal wall that were removed in the midline. The evaluation of the colon showed a perforation about 1 cm size area in the mid sigmoid colon. There is some gross spillage of stool. There are no other perforations or thickened areas appreciated, no other injuries noted. The small bowel did have a significant amount of adhesions consistent with her past surgical history of some kind of bypass surgery in the past, however, no surgical changes of the gastric lumen were noted on the EGD 72 hours ago and I did not see any evidence of this today, however, I did not run the entire length of the small bowel leaving some adhesions in place in the midabdomen. The colon otherwise was normal. The right upper quadrant showed adhesions that once they were taken down no injury to the proximal small bowel or gastric lumen appreciated. Given the perforation found in the sigmoid colon I did not pursue any further investigation of the upper abdomen. The liver was homogeneous without any isolated lesions. There did appear to be small ventral hernia to the right side of the abdominal wall as well. There was a significant amount of anterior abdominal wall adhesions appreciated that were easily taken down on opening of the laparotomy. There was noted some inflammatory changes appreciated to the omentum and the thickening of the peritoneum and the pelvis consistent with infection peritonitis type changes.
DESCRIPTION OF OPERATION
The procedure, as well as indications, benefits, 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, art line and central line were placed per anesthesia. The patient was then placed in the low lithotomy position with legs in stirrups in case we need to make a low anastomosis. The anterior abdominal wall was prepped and draped in the usual sterile fashion after a Foley catheter was placed. Ioban was placed over the abdominal wall.
A midline incision was made with a 10-blade scalpel in the upper abdomen midline. Electrocautery was used to carry dissection down to the fascia. The fascia was elevated and carefully incised with Metzenbaum scissors, With posterior protection the midline fascia was opened with electrocautery. As the wire sutures were encountered they were removed. The incision length was extended cephalad and caudad to get adequate visualization of the pelvis. The Bookwalter self-retaining retractor was placed, a bladder blade was placed and walls were retracted to visualize the colon. Some more omental adhesions and small bowel adhesions to the anterior abdominal wall were taken down, taking care not to injure or cause any full-thickness injury to the small bowel. The above findings were noted. The pelvis was irrigated with a liter of sterile saline to remove gross debris. The perforation had some soft stool leaking from it. At this point I close this perforation with interrupted Lembert 2-0 and 3-0 silk sutures to oversew this perforation in a single layer. Closure of the actual leak was then followed by further irrigation and exploration of the rest of the abdomen and takedown of anterior abdominal wall adhesions to visualize the liver and left upper quadrant, as well as the stomach and anterior structure of the duodenum. With no other significant pathology appreciated, and given the patient's recent history, I did not takedown all of the mid abdomen adhesions given her critical state and certainly did not resect the sigmoid colon at this point with her acidotic, hypothermic, hypotensive. The patient's abdomen was then irrigated with copious amounts of warm saline and no active bleeding was appreciated. The Abthera wound dressing was then cut to fit and draped over the intra-abdominal contents posterior to the peritoneal and the midline was loosely approximated with the blue sponge with gapping about 6 cm. The occlusive dressing was applied and negative pressure to the Abthera V.A.C. was then applied. The patient's Foley catheter was then placed. She was going to remain on the ventilator and she was taken to the Intensive Care Unit in stable and guarded condition. We will continue postoperative antibiotic therapy. All sponge and instrument counts were correct
DISPOSITION
We will plan to take the patient back in 24 to 72 hours for a second look procedure most likely about 48 hours from now when she is more stable to potentially close the abdominal wall. I will also have Dr. McKibben follow along for medical management and assistance in critical care management during her stay in the Intensive Care Unit. Please see the orders for complete detail.