boyced@email.chop.edu
Contributor
Hi,
Can someone please help??? My physician feels this is 46730.. I'm leaning toward 46716. Any help would be great!!
PROCEDURE:
Posterior sagittal anorectoplasty with resection of scrotal fistula
POSTOPERATIVE DIAGNOSIS:
Perineal fistula variant with extension into the scrotum
OPERATIVE PROCEDURE IN DETAIL:
After informed consent was obtained from the parents, the patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced and an endotracheal tube inserted without difficulty. Preoperative antibiotics were given and a safety timeout was performed. The urology team performed a cystoscopy and placed an 8Fr foley catheter. No fistula was visualized during the study. They then performed a circumcision. (dictated separately). The patient was positioned prone and all pressure points padded. The baby was prepped and draped in the usual sterile fashion. A stimulator was used to demonstrate the posterior and anterior limits of the sphincter and marked with a silk suture. A midline posterior sagittal incision was made by dividing the skin, subcutaneous tissue, parasagittal fibers, and muscle complex down to the coccyx. The area distal to the coccyx was dissected to identify the rectum. The rectum was found very anteriorly just posterior to the urethra. The fistula tracked through the pelvis into the base of the scrotum. Silk sutures in the rectum and divided it in the midline. I confirmed the fistula ended within the scrotum and did not communicate with the urethra by following the fistula distally into the scrotum. I removed the fistula completely from the scrotum and then placed multiple silk stitches for mobilization in the rectal wall. The rectum coursed just posterior to the urethra for the entire dissection. I then began a circumferential mobilization of the rectum taking all band attachments, and dissecting within the white fascia that envelopes the rectum, preserving the intramural blood supply. This mobilization was continued until the rectum reached the perineum. The anterior portion of the perineum was then reconstructed to form a perineal body. Then with the rectum on slight tension sutures were placed from the posterior edge of the muscle complex incorporating the posterior wall of the rectum X3 with each stitch coming more superficial on the edge of the sphincter complex. This allowed the rectum to lay with the vertical fibers muscle complex. The levator muscles were reapproximated and the posterior sagittal incision reapproximated in layers. The posterior sagittal incision was closed up to the skin. The anoplasty was performed after placing 4-0 vicryl sutures to either side of the rectum to pull the skin up to the rectum. The excess rectum and fistula were trimmed to healthy tissue. The anoplasty was completed with a series of 16 4-0 Vicryl sutures. The rest of the posterior sagittal incision was closed with interrupted Vicryl sutures at the skin level. The rectum was healthy and viable at the anoplasty which was sized to a 14 Hegar dilator, and inverted nicely after cutting of the sutures. The patient tolerated the procedure well. There were no complications The patient was transferred to the PACU in stable condition. I was present and scrubbed for all aspects of this procedure.
Can someone please help??? My physician feels this is 46730.. I'm leaning toward 46716. Any help would be great!!
PROCEDURE:
Posterior sagittal anorectoplasty with resection of scrotal fistula
POSTOPERATIVE DIAGNOSIS:
Perineal fistula variant with extension into the scrotum
OPERATIVE PROCEDURE IN DETAIL:
After informed consent was obtained from the parents, the patient was brought to the operating room and placed supine on the operating table. General anesthesia was induced and an endotracheal tube inserted without difficulty. Preoperative antibiotics were given and a safety timeout was performed. The urology team performed a cystoscopy and placed an 8Fr foley catheter. No fistula was visualized during the study. They then performed a circumcision. (dictated separately). The patient was positioned prone and all pressure points padded. The baby was prepped and draped in the usual sterile fashion. A stimulator was used to demonstrate the posterior and anterior limits of the sphincter and marked with a silk suture. A midline posterior sagittal incision was made by dividing the skin, subcutaneous tissue, parasagittal fibers, and muscle complex down to the coccyx. The area distal to the coccyx was dissected to identify the rectum. The rectum was found very anteriorly just posterior to the urethra. The fistula tracked through the pelvis into the base of the scrotum. Silk sutures in the rectum and divided it in the midline. I confirmed the fistula ended within the scrotum and did not communicate with the urethra by following the fistula distally into the scrotum. I removed the fistula completely from the scrotum and then placed multiple silk stitches for mobilization in the rectal wall. The rectum coursed just posterior to the urethra for the entire dissection. I then began a circumferential mobilization of the rectum taking all band attachments, and dissecting within the white fascia that envelopes the rectum, preserving the intramural blood supply. This mobilization was continued until the rectum reached the perineum. The anterior portion of the perineum was then reconstructed to form a perineal body. Then with the rectum on slight tension sutures were placed from the posterior edge of the muscle complex incorporating the posterior wall of the rectum X3 with each stitch coming more superficial on the edge of the sphincter complex. This allowed the rectum to lay with the vertical fibers muscle complex. The levator muscles were reapproximated and the posterior sagittal incision reapproximated in layers. The posterior sagittal incision was closed up to the skin. The anoplasty was performed after placing 4-0 vicryl sutures to either side of the rectum to pull the skin up to the rectum. The excess rectum and fistula were trimmed to healthy tissue. The anoplasty was completed with a series of 16 4-0 Vicryl sutures. The rest of the posterior sagittal incision was closed with interrupted Vicryl sutures at the skin level. The rectum was healthy and viable at the anoplasty which was sized to a 14 Hegar dilator, and inverted nicely after cutting of the sutures. The patient tolerated the procedure well. There were no complications The patient was transferred to the PACU in stable condition. I was present and scrubbed for all aspects of this procedure.