Could someone please tell me how they would code this? I'm not sure if I should use the 11008 and 10180 or something else.
Date of Service: May 20, 2014
OPERATIVE REPORT
PROCEDURE
1. Excision of infected mesh times 2 in right upper quadrant and left
upper quadrant.
2. Incision and drainage of suture abscess in the right middle
quadrant.
DRAINS
Left in Penrose drain in left upper quadrant. Total number of drains 2.
ESTIMATED BLOOD LOSS
Less than 10 mL.
COMPLICATIONS
None.
ANESTHESIA
General endotracheal.
SPECIMENS
Wound cultures in the left upper quadrant and right middle quadrant.
BRIEF HISTORY
The patient is a 53-year-old female with a history of multiple hernia
repairs, with concomitant mesh infection. Patient has received
prolonged treatment with antibiotics and currently presents with further
pain at old incision sites as well as complaints of umbilical drainage.
OPERATIVE NOTE
Upon entering the room, the patient was placed in supine position under
general endotracheal intubation. A proper time-out was then performed
using 2 forms of identification. Please note that was present and
scrubbed for the entire case. Initial attention was paid towards the
left upper quadrant. After a palpation of the skin, an area of
induration approximately 4 x 2 cm was palpated. A superficial
transverse incision was made 4 cm in length over the skin of the palpated region. Electrocautery was used to dissect down to a pocket of
infected mesh. Upon reaching the pocket, yellow sulphuric granulation
drainage was noted. Cultures were taken at this point, times 2 for
aerobic, anaerobic and AFB. The foreign body was then elevated and
completely excised from the wound pocket. Further inspection was made
noting no further palpable foreign bodies or drainage. At this point,
the wound was packed with laparotomy pad and attention was then turned
towards the right upper quadrant.
Again, a 3 x 2 cm area of induration was palpated; however, at this
point, an ultrasound was brought into the operating room, and under
image guidance, the right upper, middle, lower and midline regions were
all examined under ultrasound guidance. Initially pockets air and fluid
were seen under all of the right upper, middle, lower and midline
regions. At this point, the right upper quadrant transverse incision
was made over the area of induration that was palpated and seen under
image guidance. A transverse incision approximately 4 cm long was
performed. Dissection was taken down to another piece of foreign body,
likely old mesh. Upon entry into the cavity, dark green purulent
material was noted. Again, the mesh was elevated and completely
transected from the abdominal wall. This was again sent for aerobic,
anaerobic and AFB cultures. Further exploration of the wound showed no
other retained foreign bodies. Approximately 5 cm inferior to this in
the right middle quadrant, another region of induration approximately 2
x 2 cm was palpated. A 3 cm incision was made over this area of
induration. Electrocautery was taken down through the fat layers until
a suture abscess cavity was reached. The abscess cavity was removed and
cultured as well. The wound was then explored noting no further areas
of induration. Once again with image guidance, the right lower quadrant
was viewed noting an area of approximately 2 x 2 cm of air and fluid.
Cutdown using the technique described above was made in this region.
Upon reaching the fascial layers, nothing was able to be digitally
palpated in this region. However, upon reaching this region a careful
dissection was taken through to the abdominal wall. However, a hernia
sac that was previously existing in this region was entered. The bowel
was inspected to make sure there was no damage. The wound was packed
using a laparotomy pad.
At this point, attention was turned to the midline and once again using
ultrasound guidance, the wound was explored; however, nothing could be
seen. Upon inspection of the umbilicus there was what appeared to be a
small fistulous tract in the inferior umbilicus. Exploration with a
pair of sharp hemostats did not yield any fistulous tract that could be
cannulated. At this point, a small midline incision approximately 5 cm
in length, periumbilically was made. Using electrocautery, dissection
of the fat onto the anterior rectus fascia was made. Then 3rd dissection around the umbilicus yielded no fistulous tracts that could
be seen and no abscess cavities.
At this point, all wounds had been packed with laparotomy pads after
exploration and all the packs were removed. Penrose drain was
cannulated between the right upper and right middle quadrant, and a
Penrose drain was placed into the left upper quadrant. The superficial
skin was then closed using skin staples at all sites. Patient tolerated
the procedure well. There were no complications.
Date of Service: May 20, 2014
OPERATIVE REPORT
PROCEDURE
1. Excision of infected mesh times 2 in right upper quadrant and left
upper quadrant.
2. Incision and drainage of suture abscess in the right middle
quadrant.
DRAINS
Left in Penrose drain in left upper quadrant. Total number of drains 2.
ESTIMATED BLOOD LOSS
Less than 10 mL.
COMPLICATIONS
None.
ANESTHESIA
General endotracheal.
SPECIMENS
Wound cultures in the left upper quadrant and right middle quadrant.
BRIEF HISTORY
The patient is a 53-year-old female with a history of multiple hernia
repairs, with concomitant mesh infection. Patient has received
prolonged treatment with antibiotics and currently presents with further
pain at old incision sites as well as complaints of umbilical drainage.
OPERATIVE NOTE
Upon entering the room, the patient was placed in supine position under
general endotracheal intubation. A proper time-out was then performed
using 2 forms of identification. Please note that was present and
scrubbed for the entire case. Initial attention was paid towards the
left upper quadrant. After a palpation of the skin, an area of
induration approximately 4 x 2 cm was palpated. A superficial
transverse incision was made 4 cm in length over the skin of the palpated region. Electrocautery was used to dissect down to a pocket of
infected mesh. Upon reaching the pocket, yellow sulphuric granulation
drainage was noted. Cultures were taken at this point, times 2 for
aerobic, anaerobic and AFB. The foreign body was then elevated and
completely excised from the wound pocket. Further inspection was made
noting no further palpable foreign bodies or drainage. At this point,
the wound was packed with laparotomy pad and attention was then turned
towards the right upper quadrant.
Again, a 3 x 2 cm area of induration was palpated; however, at this
point, an ultrasound was brought into the operating room, and under
image guidance, the right upper, middle, lower and midline regions were
all examined under ultrasound guidance. Initially pockets air and fluid
were seen under all of the right upper, middle, lower and midline
regions. At this point, the right upper quadrant transverse incision
was made over the area of induration that was palpated and seen under
image guidance. A transverse incision approximately 4 cm long was
performed. Dissection was taken down to another piece of foreign body,
likely old mesh. Upon entry into the cavity, dark green purulent
material was noted. Again, the mesh was elevated and completely
transected from the abdominal wall. This was again sent for aerobic,
anaerobic and AFB cultures. Further exploration of the wound showed no
other retained foreign bodies. Approximately 5 cm inferior to this in
the right middle quadrant, another region of induration approximately 2
x 2 cm was palpated. A 3 cm incision was made over this area of
induration. Electrocautery was taken down through the fat layers until
a suture abscess cavity was reached. The abscess cavity was removed and
cultured as well. The wound was then explored noting no further areas
of induration. Once again with image guidance, the right lower quadrant
was viewed noting an area of approximately 2 x 2 cm of air and fluid.
Cutdown using the technique described above was made in this region.
Upon reaching the fascial layers, nothing was able to be digitally
palpated in this region. However, upon reaching this region a careful
dissection was taken through to the abdominal wall. However, a hernia
sac that was previously existing in this region was entered. The bowel
was inspected to make sure there was no damage. The wound was packed
using a laparotomy pad.
At this point, attention was turned to the midline and once again using
ultrasound guidance, the wound was explored; however, nothing could be
seen. Upon inspection of the umbilicus there was what appeared to be a
small fistulous tract in the inferior umbilicus. Exploration with a
pair of sharp hemostats did not yield any fistulous tract that could be
cannulated. At this point, a small midline incision approximately 5 cm
in length, periumbilically was made. Using electrocautery, dissection
of the fat onto the anterior rectus fascia was made. Then 3rd dissection around the umbilicus yielded no fistulous tracts that could
be seen and no abscess cavities.
At this point, all wounds had been packed with laparotomy pads after
exploration and all the packs were removed. Penrose drain was
cannulated between the right upper and right middle quadrant, and a
Penrose drain was placed into the left upper quadrant. The superficial
skin was then closed using skin staples at all sites. Patient tolerated
the procedure well. There were no complications.