roses23
New
I've never had this one b4: Doc did a reattachment of the puborectalis muscle bilaterally thru the rectum for avulsion of the muscle here is his dictation on that part of the complete surgery he did:
On anal inspection it was found that the patient did not have an angle at all. It was very straight and one could detect that both arms of the puborectalis on each side had been separated. There was no typical U-shape and no elevation of the rectum. Making 2 lateral incisions on each side of the rectum behind the perineal body, we dissected down and then a tunnel was dissected up to the symphysis approximately in the place where the normal insertion of the muscle would be. Using the Capio device with Vicryl we attached a stitch. We were able to come down and find the end of the puborectalis muscle by dissecting down the graft with an Allis. As were pulled up one could feel the elevation of the rectum on that side. This was then attached behind the symphysis and this was done on the other side in a similar fashion so at the end of the case the anorectal junction had been elevated approximately 2-3 cm. The posterior endopelvic fascia and the lateral fascia were reattached over the area that we dissected. This gave good lateral support and central part of the perineal body and the descent of the perineal body was no longer apparent. The perineal body, it was felt that the Colles fascia and the perineal membrane had separated and retracted to her left. We dissected down until we found this and we were able to bring them back and reattach it to the other side in a series of interrupted stitches. Because of the poor quality tissue both anterior and posterior, we elected to use mesh as a supplement and so we elected to put the next procedure that will be the posterior elevate and the series of interrupted stitches were placed around the periphery of where the mesh was still lying to be able to attach the edges using the Capio with Vicryl. The sacrospinous ligaments were attached, the arms where the posterior elevate were attached approximately 1 cm down from the spine on each side. The mesh was slid over the arms into position to make sure there is no difference between the mesh and the rectum and it was locked into place and then sewed into position. Then 3 stitches were used around the area of the perineal body and attached to this area also. At this point, she had very good posterior support and anterior support of the perineal body good support and the anus was good support and she had a good elevation of the crease of her buttocks. The vaginal mucosa was closed with 2-0 Vicryl in a horizontal mattress. Because the puborectalis muscle was still attached to the medial sides of the perineal body this closed down the genital hiatus very nicely. The puborectalis muscle was reapproximated and then the tissue above the perineal membrane was closed with a series of interrupted stitches and the skin closed subcuticularly.
That is exactly how it was dictated and I have no clue how to code this. The only thing I can come up with is 20999 Unlisted procedure for the musculoskeletal system. Any help or leads would be greatly appreciated. Thanks.
On anal inspection it was found that the patient did not have an angle at all. It was very straight and one could detect that both arms of the puborectalis on each side had been separated. There was no typical U-shape and no elevation of the rectum. Making 2 lateral incisions on each side of the rectum behind the perineal body, we dissected down and then a tunnel was dissected up to the symphysis approximately in the place where the normal insertion of the muscle would be. Using the Capio device with Vicryl we attached a stitch. We were able to come down and find the end of the puborectalis muscle by dissecting down the graft with an Allis. As were pulled up one could feel the elevation of the rectum on that side. This was then attached behind the symphysis and this was done on the other side in a similar fashion so at the end of the case the anorectal junction had been elevated approximately 2-3 cm. The posterior endopelvic fascia and the lateral fascia were reattached over the area that we dissected. This gave good lateral support and central part of the perineal body and the descent of the perineal body was no longer apparent. The perineal body, it was felt that the Colles fascia and the perineal membrane had separated and retracted to her left. We dissected down until we found this and we were able to bring them back and reattach it to the other side in a series of interrupted stitches. Because of the poor quality tissue both anterior and posterior, we elected to use mesh as a supplement and so we elected to put the next procedure that will be the posterior elevate and the series of interrupted stitches were placed around the periphery of where the mesh was still lying to be able to attach the edges using the Capio with Vicryl. The sacrospinous ligaments were attached, the arms where the posterior elevate were attached approximately 1 cm down from the spine on each side. The mesh was slid over the arms into position to make sure there is no difference between the mesh and the rectum and it was locked into place and then sewed into position. Then 3 stitches were used around the area of the perineal body and attached to this area also. At this point, she had very good posterior support and anterior support of the perineal body good support and the anus was good support and she had a good elevation of the crease of her buttocks. The vaginal mucosa was closed with 2-0 Vicryl in a horizontal mattress. Because the puborectalis muscle was still attached to the medial sides of the perineal body this closed down the genital hiatus very nicely. The puborectalis muscle was reapproximated and then the tissue above the perineal membrane was closed with a series of interrupted stitches and the skin closed subcuticularly.
That is exactly how it was dictated and I have no clue how to code this. The only thing I can come up with is 20999 Unlisted procedure for the musculoskeletal system. Any help or leads would be greatly appreciated. Thanks.