Hi,
Could I get some thoughts on the operative report below. Any suggestions would be appreciated. I'm thinking 10121 for the foreign body removal but I 'm not sure about the excision of the tract. Thanks
PREOPERATIVE DIAGNOSIS
Chronic nonhealing suprapubic mass.
POSTOPERATIVE DIAGNOSIS
Chronic nonhealing suprapubic mass.
PROCEDURE
1. Open excision of chronic nonhealing suprapubic mass size 9 x 4 x
2.5 cm.
2. Open removal of foreign body. Both of those procedures were done
by Dr.
3. Dr. did a flexible cystoscopy. Please see his dictation for
details.
ANESTHESIA
General endotracheal anesthesia.
ESTIMATED BLOOD LOSS
Approximately 25 mL.
COMPLICATIONS
None.
CONDITION
Stable.
SPECIMEN
1. Foreign body suspicious for suture sent to pathology.
2. Suprapubic mass with a fistulous tract size 9 x 4 x 2.5 cm sent to
pathology.
3. Cultures were sent for gram stain, culture and sensitivity both
aerobic and anaerobic of this chronic non-healing suprapubic mass.
COMPLICATIONS
None.
CONDITION
Stable.
DRAINS
None.
COUNTS
Correct times 2.
INDICATIONS FOR PROCEDURE
Ms. Tavera is an 80-year-old female who presented to my clinic with a
chronic non-healing suprapubic mass. Imaging consisting of CT scan and
ultrasound revealed a solid suprapubic subcutaneous mass suspicious for
mass versus phlegmon. The patient did had a past surgical history of a
bladder sling in the past. Risks, benefits and alternatives of surgical
intervention, specifically open excision of this mass and any other
indicated procedures were explained to the patient in great detail. All
questions were answered. The patient agreed to proceed with surgical
intervention. Consents were signed freely.
REPORT OF PROCEDURE
The patient was given preoperative IV antibiotics and SCD's were placed
to bilateral lower extremities. Heparin was not given as the patient
has a Lovenox injection. She was bridged with Lovenox by another
physician of hers as she was holding her Plavix for this surgery. She
will get back on her Plavix after surgery. SCD's were placed to
bilateral lower extremities. The patient was then taken to the
operating theater and placed supine on the operating table after
adequate IV sedation and intubation by anesthesia. The patient's
suprapubic and groin regions were prepped and draped in the standard
sterile surgical fashion. Cultures were first taken of this chronic nonhealing
wound specifically of the sinus tract that was draining some
material. These were sent for aerobic and anaerobic sensitivities. An
elliptical incision was then made around this chronic non-healing mass.
Electrocautery was used to dissect deep dermal layers. The fistulous
tract was identified and this dissection carried down to the pubic bone.
A foreign body was identified and removed. This was suspicious for suture likely secondary to her past bladder sling. This fistulous tract
continued deep past the pubic bone with suspicion that this may be
either into bladder or potentially vagina versus just an epithelialized
fistulous tract secondary to foreign body reaction and phlegmon
formation. I elected to place an intraoperative consult to one of my
urology colleagues Dr. who came in, examined this fistulous
tract and decided to do a flexible cystoscopy which was done which
showed no communication between the bladder and the fistulous tract. We
also did a vaginal exam and again there was no connection between this
fistulous tract and the vagina. Please see Dr. dictation for
details regarding his part of the case. We elected to fulgurate the
epithelial lining of this fistulous tract that went deep to the pubic
bone. This was done with electrocautery. The specimen was then removed
size 9 x 4 x 2.5 cm and sent to pathology as a specimen. The incision
was inspected hemostasis was achieved and confirmed per visual
inspection. I did elect to place some Arista powder in the incision due
to the patient getting back on Plavix in the near future. The incision
was then closed in layers with 3-0 Vicryl in 2 different layers for deep
dermal and superficial dermal and 4-0 Monocryl in a running fashion for
the skin. Steri-Strips and clean sterile pressure dressing were applied.
All counts were correct at the end of the case. The patient tolerated
the procedure well and without complication and was returned to recovery
room awake, alert and in good condition.
Could I get some thoughts on the operative report below. Any suggestions would be appreciated. I'm thinking 10121 for the foreign body removal but I 'm not sure about the excision of the tract. Thanks
PREOPERATIVE DIAGNOSIS
Chronic nonhealing suprapubic mass.
POSTOPERATIVE DIAGNOSIS
Chronic nonhealing suprapubic mass.
PROCEDURE
1. Open excision of chronic nonhealing suprapubic mass size 9 x 4 x
2.5 cm.
2. Open removal of foreign body. Both of those procedures were done
by Dr.
3. Dr. did a flexible cystoscopy. Please see his dictation for
details.
ANESTHESIA
General endotracheal anesthesia.
ESTIMATED BLOOD LOSS
Approximately 25 mL.
COMPLICATIONS
None.
CONDITION
Stable.
SPECIMEN
1. Foreign body suspicious for suture sent to pathology.
2. Suprapubic mass with a fistulous tract size 9 x 4 x 2.5 cm sent to
pathology.
3. Cultures were sent for gram stain, culture and sensitivity both
aerobic and anaerobic of this chronic non-healing suprapubic mass.
COMPLICATIONS
None.
CONDITION
Stable.
DRAINS
None.
COUNTS
Correct times 2.
INDICATIONS FOR PROCEDURE
Ms. Tavera is an 80-year-old female who presented to my clinic with a
chronic non-healing suprapubic mass. Imaging consisting of CT scan and
ultrasound revealed a solid suprapubic subcutaneous mass suspicious for
mass versus phlegmon. The patient did had a past surgical history of a
bladder sling in the past. Risks, benefits and alternatives of surgical
intervention, specifically open excision of this mass and any other
indicated procedures were explained to the patient in great detail. All
questions were answered. The patient agreed to proceed with surgical
intervention. Consents were signed freely.
REPORT OF PROCEDURE
The patient was given preoperative IV antibiotics and SCD's were placed
to bilateral lower extremities. Heparin was not given as the patient
has a Lovenox injection. She was bridged with Lovenox by another
physician of hers as she was holding her Plavix for this surgery. She
will get back on her Plavix after surgery. SCD's were placed to
bilateral lower extremities. The patient was then taken to the
operating theater and placed supine on the operating table after
adequate IV sedation and intubation by anesthesia. The patient's
suprapubic and groin regions were prepped and draped in the standard
sterile surgical fashion. Cultures were first taken of this chronic nonhealing
wound specifically of the sinus tract that was draining some
material. These were sent for aerobic and anaerobic sensitivities. An
elliptical incision was then made around this chronic non-healing mass.
Electrocautery was used to dissect deep dermal layers. The fistulous
tract was identified and this dissection carried down to the pubic bone.
A foreign body was identified and removed. This was suspicious for suture likely secondary to her past bladder sling. This fistulous tract
continued deep past the pubic bone with suspicion that this may be
either into bladder or potentially vagina versus just an epithelialized
fistulous tract secondary to foreign body reaction and phlegmon
formation. I elected to place an intraoperative consult to one of my
urology colleagues Dr. who came in, examined this fistulous
tract and decided to do a flexible cystoscopy which was done which
showed no communication between the bladder and the fistulous tract. We
also did a vaginal exam and again there was no connection between this
fistulous tract and the vagina. Please see Dr. dictation for
details regarding his part of the case. We elected to fulgurate the
epithelial lining of this fistulous tract that went deep to the pubic
bone. This was done with electrocautery. The specimen was then removed
size 9 x 4 x 2.5 cm and sent to pathology as a specimen. The incision
was inspected hemostasis was achieved and confirmed per visual
inspection. I did elect to place some Arista powder in the incision due
to the patient getting back on Plavix in the near future. The incision
was then closed in layers with 3-0 Vicryl in 2 different layers for deep
dermal and superficial dermal and 4-0 Monocryl in a running fashion for
the skin. Steri-Strips and clean sterile pressure dressing were applied.
All counts were correct at the end of the case. The patient tolerated
the procedure well and without complication and was returned to recovery
room awake, alert and in good condition.