D.R.
Networker
Hi all! Need help regarding what code to use for the prolene mesh used to reconstruct the abdominoperineal defect. My provider wants to use 49568 but there is no hernia. Would appreciate your input please. Thanks
Pre-Op Diagnosis : Rectal cancer
Post-Op Diagnosis : Same
VERTICAL RECTUS ABDOMINIS MYOCUTANEOUS FLAP FOR RECONSTRUCTION OF ABDOMINOPERINEAL RESECTION DEFECT
After the colorectal surgeon had performed the APR and sigmoid colostomy with ostomy placement on the left abdomen, we returned to inset the VRAM flap into the perineal defect and to close and repair the donor abdominal site. The perineal defect was measured at 11 x 5 cm. We proceeded with dunking the VRAM flap into the abdomen and passed the defect and planned the inset as well as the amount of skin and subcutaneous tissue that would need to be excised from the proximal portion of the flap that was excess. Once that was done, the flap was then brought back out of the abdomen and the excess skin and subcutaneous fat was excised utilizing Bovie electrocautery as well as a 15 blade. Once that was done, the VRAM flap was then rotated 90 degrees making sure not to kink the vascular pedicle and not place any undue pressure on the pedicle itself the VRAM was pulled through the APR defect and into the perineal defect and positioned accordingly in order to cover the defect. The flap was noted to be well-perfused with good capillary refill and was warm to the touch. There was healthy bleeding from the edge of the flap. We then placed a 19 French Blake drain within the defect along the site of the flap which exited out and was secured in place with a 2-0 silk suture. We then proceeded with suturing the flap into place utilizing buried interrupted 3-0 Vicryl suture for the deep dermis followed by simple running 3-0 Chromic Gut sutures in various levels. Simple interrupted 3-0 nylon sutures were also utilized. The flap appeared to be well-perfused at the end of the suturing as well.
In order to close the abdomen, we ran a 0 PDS to close the peritoneum and the posterior sheath with the assistance of muscle relaxation and a fish to keep the bowels at bay. A Prolene mesh was trimmed to 22 cm x 5 cm to fit the defect of the entire length of the anterior rectus sheath and inset using short runs of running #1 prolene to inset the mesh under the lateral leaf of rectus fascia and to the midline of the linea alba. The closure included the superior and inferior borders of the harvest. A #15 Blake drain was then exteriorized through the lateral abdominal skin, and sewn in with a 2-0 silk, The wound was then irrigated with antibiotic solution and full strength Betadine was used to coat the mesh and the subcutaneous space. The skin was then closed with 3-0 Vicryl for the dep dermal layer, and the skin was closed with a running subcuticular 4-0 Monocryl. The length of the skin closure in intermediate fashion was 28 cm.
Pre-Op Diagnosis : Rectal cancer
Post-Op Diagnosis : Same
VERTICAL RECTUS ABDOMINIS MYOCUTANEOUS FLAP FOR RECONSTRUCTION OF ABDOMINOPERINEAL RESECTION DEFECT
After the colorectal surgeon had performed the APR and sigmoid colostomy with ostomy placement on the left abdomen, we returned to inset the VRAM flap into the perineal defect and to close and repair the donor abdominal site. The perineal defect was measured at 11 x 5 cm. We proceeded with dunking the VRAM flap into the abdomen and passed the defect and planned the inset as well as the amount of skin and subcutaneous tissue that would need to be excised from the proximal portion of the flap that was excess. Once that was done, the flap was then brought back out of the abdomen and the excess skin and subcutaneous fat was excised utilizing Bovie electrocautery as well as a 15 blade. Once that was done, the VRAM flap was then rotated 90 degrees making sure not to kink the vascular pedicle and not place any undue pressure on the pedicle itself the VRAM was pulled through the APR defect and into the perineal defect and positioned accordingly in order to cover the defect. The flap was noted to be well-perfused with good capillary refill and was warm to the touch. There was healthy bleeding from the edge of the flap. We then placed a 19 French Blake drain within the defect along the site of the flap which exited out and was secured in place with a 2-0 silk suture. We then proceeded with suturing the flap into place utilizing buried interrupted 3-0 Vicryl suture for the deep dermis followed by simple running 3-0 Chromic Gut sutures in various levels. Simple interrupted 3-0 nylon sutures were also utilized. The flap appeared to be well-perfused at the end of the suturing as well.
In order to close the abdomen, we ran a 0 PDS to close the peritoneum and the posterior sheath with the assistance of muscle relaxation and a fish to keep the bowels at bay. A Prolene mesh was trimmed to 22 cm x 5 cm to fit the defect of the entire length of the anterior rectus sheath and inset using short runs of running #1 prolene to inset the mesh under the lateral leaf of rectus fascia and to the midline of the linea alba. The closure included the superior and inferior borders of the harvest. A #15 Blake drain was then exteriorized through the lateral abdominal skin, and sewn in with a 2-0 silk, The wound was then irrigated with antibiotic solution and full strength Betadine was used to coat the mesh and the subcutaneous space. The skin was then closed with 3-0 Vicryl for the dep dermal layer, and the skin was closed with a running subcuticular 4-0 Monocryl. The length of the skin closure in intermediate fashion was 28 cm.