knperry
Guru
My doc performed a procedure where he restored continuity and closure of abdomen. Not sure how to code this. Would appreciate any input. Please see notes below:
INDICATIONS FOR PROCEDURE: This is a 44-year-old female, who presented to thetrauma bay approximately 2 days ago, status post MVC with hypotension and a positive FAST, was emergently taken to the OR for a trauma ex-lap and upon on the ex-lap it was seen that she had a bowel injury and hematoma with active arterial bleeding at that time and a small portion of the _____ ileum was resected and the mesenteric bleed was tied off and _____ was placed and ABThera was placed for patient to return to the OR in 48-72 hours.
DESCRIPTION OF PROCEDURE: Preoperatively consent was obtained from patient's mother and patient was brought to the operating room in supine position. Abdomen was prepped and draped in the usual sterile fashion. Time-out was done. The ABThera wound VAC was removed and the abdomen was copiously irrigated and the Pulse lavage was used without the suction portion with Clorpactin to wash out the abdomen and it was noted that there was a pinpoint hole in the small bowel, this section was closed primarily. The abdomen was again washed out with Clorpactin. The small bowel and colon _____ no obvious injuries were noted. The hematoma in the mesentery was stable. Decision was made to restore continuity of the ileal resection that was done previously 2 days ago. The GIA-75 stapler was used to make the anastomosis in side-to-side fashion. The mesenteric defect was then sewn together to ensure no internal hernia was obtained through this site. The abdomen was washed out again in all 4 quadrants and the abdomen was inspected. Decision was made to close the fascia with a running looped PDS and the skin was closed with a stapler. Patient tolerated procedure well. Peak pressures remained below 30. Patient was taken to postanesthesia care unit in stable condition.
INDICATIONS FOR PROCEDURE: This is a 44-year-old female, who presented to thetrauma bay approximately 2 days ago, status post MVC with hypotension and a positive FAST, was emergently taken to the OR for a trauma ex-lap and upon on the ex-lap it was seen that she had a bowel injury and hematoma with active arterial bleeding at that time and a small portion of the _____ ileum was resected and the mesenteric bleed was tied off and _____ was placed and ABThera was placed for patient to return to the OR in 48-72 hours.
DESCRIPTION OF PROCEDURE: Preoperatively consent was obtained from patient's mother and patient was brought to the operating room in supine position. Abdomen was prepped and draped in the usual sterile fashion. Time-out was done. The ABThera wound VAC was removed and the abdomen was copiously irrigated and the Pulse lavage was used without the suction portion with Clorpactin to wash out the abdomen and it was noted that there was a pinpoint hole in the small bowel, this section was closed primarily. The abdomen was again washed out with Clorpactin. The small bowel and colon _____ no obvious injuries were noted. The hematoma in the mesentery was stable. Decision was made to restore continuity of the ileal resection that was done previously 2 days ago. The GIA-75 stapler was used to make the anastomosis in side-to-side fashion. The mesenteric defect was then sewn together to ensure no internal hernia was obtained through this site. The abdomen was washed out again in all 4 quadrants and the abdomen was inspected. Decision was made to close the fascia with a running looped PDS and the skin was closed with a stapler. Patient tolerated procedure well. Peak pressures remained below 30. Patient was taken to postanesthesia care unit in stable condition.