michea
New
I am a coder in an ASC and this procedure has been haunting me. This procedure is done before her TRAM flap reconstruction to insure optimal healing and flap survival.
Thanks
PREOPERATIVE DIAGNOSIS: Acquired right breast deformity status post right
breast cancer.
POSTOPERATIVE DIAGNOSIS: Acquired right breast deformity status post right
breast cancer.
PROCEDURE: Left groin vascular delay procedure.
ANESTHESIA: MAC plus local (approximately 17 mL of a mixture of 2% lidocaine
with epinephrine and 0.5% plain Marcaine).
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Approximately 850 mL of Crystalloid.
SPECIMEN: None.
DRAINS: None.
Condition to recovery room stable.
FINDINGS: The thin patient with slightly different anatomy.
IDENTIFICATION: The patient is a 64-year-old African American female with
history of hypertension and right breast cancer. She was seen for initial
consultation on 11/13/2006 for an immediate TRAM flap reconstruction. The
patient refuses implant reconstruction. Because of possible skin involvement
and locally advanced breast cancer, she underwent a right modified radical
mastectomy by Dr. Tette on 11/17/2006 without any reconstruction. She is now
status post chemotherapy and radiation therapy to the right breast and chest
wall. She was seen for a second opinion by Dr.__________ on 3/14/2007. She
then returned for a second visit evaluation on 7/30/2008. Her left mammogram
on 12/14/2007 was negative. The patient presents for delayed right breast
TRAM flap reconstruction at Holy Cross Hospital on 10/17/2008. She presents 1
week earlier for the vascular delay procedure to insure optimal healing and
flap survival. The procedure, alternatives, benefits, risks and
complications were discussed including wound dehiscence and infection, pain,
bleeding, etc. were discussed. The patient seems to understand and wished to
proceed.
DESCRIPTION OF PROCEDURE: After proper name band identification and marking
of the correct operative location, the patient was brought to the operating
table, placed in the supine position. After successful MAC anesthesia was
obtained, the left lower quadrant abdominal and groin areas were prepped and
draped in the usual sterile fashion. Local anesthetic was infiltrated. Of
note, preoperative markings were performed in the standing upright position.
The patient has a generous but slightly atrophic lower abdominal pannus.
Using the 15-blade scalpel a transverse skin incision was made starting
approximately 2 fingerbreadths above the midline pubic tubercle and 2
fingerbreadths to the left. The incision was made and was approximately 4 cm
wide. The deep dermis and the subcutaneous layers were divided with
electrocautery. Because the incision was the low, the external oblique was
divided as well as some of the internal oblique muscle to find the deep
inferior epigastric vessels. However, this dissection was too lateral
initially and the dissection then was carried more medial, dividing the left
anterior rectus sheath with electrocautery. During this section which was
carried to inferior, the transversalis fascia was divided area. There
appeared to be resemblance of small bowel underneath. By looking slightly
superior and lateral on the edge of the left rectus sheath, the deep inferior
epigastric vessels were identified without much adipose layer covering. These
were ligated proximally and distally with hemoclips and the central left deep
inferior epigastric artery was divided with the Metzenbaum scissors after
ligation proximally and distally with 2-0 silk and multiple hemoclips. The
straddling venae comitantes veins were also ligated with interrupted 2-0 silk,
but not cut. The central artery was divided with the Metzenbaum scissors.
The wound was irrigated and closed in the few fascial areas with interrupted 2-
0 Vicryl and a running 3-0 Vicryl for the fascia and the internal and external
oblique layers laterally. The anterior rectus fascia was closed with running
3-0 Vicryl. Scarpa's was closed with interrupted 2-0 Vicryl. The deep dermis
was closed with interrupted 3-0 Caprosyn suture and the skin was closed with a
running subcuticular 4-0 Caprosyn. The incision was then dressed with
Mastisol, Steri-Strips and a gauze pressure dressing. Local anesthetic was
infiltrated into the wound throughout the procedure. The patient tolerated
the procedure well. Hemostasis was achieved by electrocautery throughout
entire procedure. At the end all instrument, sponge and needle counts were
correct.
Thanks
PREOPERATIVE DIAGNOSIS: Acquired right breast deformity status post right
breast cancer.
POSTOPERATIVE DIAGNOSIS: Acquired right breast deformity status post right
breast cancer.
PROCEDURE: Left groin vascular delay procedure.
ANESTHESIA: MAC plus local (approximately 17 mL of a mixture of 2% lidocaine
with epinephrine and 0.5% plain Marcaine).
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Approximately 850 mL of Crystalloid.
SPECIMEN: None.
DRAINS: None.
Condition to recovery room stable.
FINDINGS: The thin patient with slightly different anatomy.
IDENTIFICATION: The patient is a 64-year-old African American female with
history of hypertension and right breast cancer. She was seen for initial
consultation on 11/13/2006 for an immediate TRAM flap reconstruction. The
patient refuses implant reconstruction. Because of possible skin involvement
and locally advanced breast cancer, she underwent a right modified radical
mastectomy by Dr. Tette on 11/17/2006 without any reconstruction. She is now
status post chemotherapy and radiation therapy to the right breast and chest
wall. She was seen for a second opinion by Dr.__________ on 3/14/2007. She
then returned for a second visit evaluation on 7/30/2008. Her left mammogram
on 12/14/2007 was negative. The patient presents for delayed right breast
TRAM flap reconstruction at Holy Cross Hospital on 10/17/2008. She presents 1
week earlier for the vascular delay procedure to insure optimal healing and
flap survival. The procedure, alternatives, benefits, risks and
complications were discussed including wound dehiscence and infection, pain,
bleeding, etc. were discussed. The patient seems to understand and wished to
proceed.
DESCRIPTION OF PROCEDURE: After proper name band identification and marking
of the correct operative location, the patient was brought to the operating
table, placed in the supine position. After successful MAC anesthesia was
obtained, the left lower quadrant abdominal and groin areas were prepped and
draped in the usual sterile fashion. Local anesthetic was infiltrated. Of
note, preoperative markings were performed in the standing upright position.
The patient has a generous but slightly atrophic lower abdominal pannus.
Using the 15-blade scalpel a transverse skin incision was made starting
approximately 2 fingerbreadths above the midline pubic tubercle and 2
fingerbreadths to the left. The incision was made and was approximately 4 cm
wide. The deep dermis and the subcutaneous layers were divided with
electrocautery. Because the incision was the low, the external oblique was
divided as well as some of the internal oblique muscle to find the deep
inferior epigastric vessels. However, this dissection was too lateral
initially and the dissection then was carried more medial, dividing the left
anterior rectus sheath with electrocautery. During this section which was
carried to inferior, the transversalis fascia was divided area. There
appeared to be resemblance of small bowel underneath. By looking slightly
superior and lateral on the edge of the left rectus sheath, the deep inferior
epigastric vessels were identified without much adipose layer covering. These
were ligated proximally and distally with hemoclips and the central left deep
inferior epigastric artery was divided with the Metzenbaum scissors after
ligation proximally and distally with 2-0 silk and multiple hemoclips. The
straddling venae comitantes veins were also ligated with interrupted 2-0 silk,
but not cut. The central artery was divided with the Metzenbaum scissors.
The wound was irrigated and closed in the few fascial areas with interrupted 2-
0 Vicryl and a running 3-0 Vicryl for the fascia and the internal and external
oblique layers laterally. The anterior rectus fascia was closed with running
3-0 Vicryl. Scarpa's was closed with interrupted 2-0 Vicryl. The deep dermis
was closed with interrupted 3-0 Caprosyn suture and the skin was closed with a
running subcuticular 4-0 Caprosyn. The incision was then dressed with
Mastisol, Steri-Strips and a gauze pressure dressing. Local anesthetic was
infiltrated into the wound throughout the procedure. The patient tolerated
the procedure well. Hemostasis was achieved by electrocautery throughout
entire procedure. At the end all instrument, sponge and needle counts were
correct.