Any help with the following op note would be greatly appreciated. I have come up with 35621, 35907, 47600, 36580, and 36580-59
Left axillofemoral bypass.
2. Reexploration of abdomen.
3. Removal of infected aortic prosthesis
4. Closure of inframesenteric aorta.
4. Ligation of left common iliac artery.
5. Cholecystectomy.
6. Placement of ABThera abdominal closure device.
FINDINGS: Successful establishment of the left axillofemoral bypass to the mid common femoral artery. These wounds were then closed. The abdominal closure device was removed, abdomen was reexplored. The aorta was clamped below the level of the celiac artery. The capsule was opened. The graft was swimming in a pool of pus and biofilm. The graft was divided and resected up to the proximal anastomosis.
The previous felt cuff was removed completely. The aorta was dissected free at this level to allow closure. This was done using interrupted 3-0 Prolene sutures in 3 layers. The left common iliac artery was then ligated. The entire prosthetic was removed. Due to the swollen turgidity of his gallbladder and potential for gallbladder related complications, I performed an open cholecystectomy. The right hepatorenal bypass was widely patent with a nice graft pulse. The left kidney was sacrificed. The abdomen was left open and covered with an ABThera suction device.
DESCRIPTION OF PROCEDURE: After obtaining informed consent from his wife, the patient was brought to the operating room and intubated. He was in acute renal failure and the continuous renal replacement therapy was discontinued in the ICU. Antibiotics were given. A timeout was completed. The patient was positioned supine. The legs, abdomen and chest were then prepped and draped in standard sterile fashion. Working in teams, the left axillary artery was exposed via a standard infraclavicular approach. Dissection was carried down through the skin and soft tissue.
Entry to the deeper space was accmplished between fibers of the pectoralis major muscle. Pectoralis minor muscle was divided at its insertion. The cephalic vein was ligated between silk ties and the axillary artery was exposed and encircled with umbilical tape. The previous longitudinal left femoral incision was reopened and vascular structures re-exposed. This revealed the common femoral artery with the cryo-preserved superficial femoral vein femoral-femoral bypass. The external iliac and inferior epigastric, superficial circumflex femoral arteries were all encircled with vessel loops.
A tunnel was created and an 8 mm ringed PTFE graft was tunneled below the level of the pectoralis minor muscle. Ten thousand units of heparin were given; ACT confirmed to be in the 250 to 300 range.
Clamps were placed on the axillary artery. Longitudinal arteriotomy was created. The graft was spatulated and a running 5-0 Prolene anastomosis was performed. Co-Seal was administered. Hemostasis appeared to be good.
We then focused our attention to the distal anastomosis. Clamps were placed proximally and distally. A longitudinal arteriotomy was created. The graft was cut to length, spatulated and an accessory running 6-0 Prolene anastomosis completed. Prior to completion, the vessels were flushed and the graft was deaired. Upon completion, hemostasis was good. There was a nice graft pulse. Following assurance of hemostasis, wounds were closed in layers using interrupted 2-0 and 3-0 Vicryl suture and Dermabond.
At this point, the wounds were kept covered. The abdominal ABThera device was removed. This revealed the massively distended colon and viscera. This was placed in a bowel bag. The hepatorenal bypass was checked and had a nice pulse. The abdominal contents were then rotated to expose the previously dissected aortic structures. All vessel loops were sorted out again. Additional bolus of heparin was given. The superior mesenteric artery was controlled with a Rumel loop. A DeBakey aortic clamp was placed at the level of the infraceliac aorta. The external and internal iliac arteries were secured with hypogastric clamps.
The capsule was then entered. The main body graft was visible. There was frank pus and slime all around it. This was sent for culture. The capsule was opened, graft was divided and dissection carried up to the proximal anastomosis. Ultimately, the tissue surrounding the previous graft and all the prosthetic material was removed. The entire felt pledget was dissected free. The quality of the aorta here was moderate. The left renal artery was sacrificed.
The aorta and capsule surrounding this area were freed to provide closure of the aortic stump. This was accomplished using interrupted 3-0 Prolene sutures in 3 longitudinal rows of U stitches. Following completion of this, hemostasis was good. Clamps were removed and flow restored to the superior mesenteric artery. There was a palpable pulse and a strong Doppler signal in the artery.
We then focused our attention removing the remainder of the graft. The anastomosis to the left common iliac artery was removed in its entirety. At this point, the left common iliac artery was oversewn with 3-0 Prolene suture and 0 silk ties. Clamps were removed off the external and internal iliac arteries. There was a good pulse at the level of the iliac bifurcation with preservation of the left hypogastric artery. Following this, the capsule was mechanically debrided but not frankly resected. The wound was reinspected for hemostasis, which was adequate.
Attention was then focused back over to the right side of the abdomen. The gallbladder was identified. The peritoneal attachments of the gallbladder were taken down in a top down fashion. The cystic artery was identified and ligated between silk ties. Dissection proceeded down to the cystic duct and the entire gallbladder was dangling freely off of this. We then divided it and oversewn it with 3-0 Maxon suture. This specimen was sent to pathology.
With this complete, the hepatorenal bypass was reinspected and again still had a nice palpable pulse. Two 10 French fluted Blake drains were placed in the abdomen, one in the cavity of the aortic capsule and then an additional drain in the left upper quadrant near the pancreatic tail. A tongue of omentum was freed and placed down in the retroperitoneum in the resection bed. The abdominal contents were then placed back in their normal positions and a new ABThera device was applied over the open wound.
At the end of this, he had an existing left internal jugular Mahurkar dialysis catheter and right internal jugular Cordis catheter. New clean drapes were placed and these were exchanged under sterile conditions using Seldinger technique to a left internal jugular triple-lumen catheter and a right internal jugular Trialysis catheter.
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Left axillofemoral bypass.
2. Reexploration of abdomen.
3. Removal of infected aortic prosthesis
4. Closure of inframesenteric aorta.
4. Ligation of left common iliac artery.
5. Cholecystectomy.
6. Placement of ABThera abdominal closure device.
FINDINGS: Successful establishment of the left axillofemoral bypass to the mid common femoral artery. These wounds were then closed. The abdominal closure device was removed, abdomen was reexplored. The aorta was clamped below the level of the celiac artery. The capsule was opened. The graft was swimming in a pool of pus and biofilm. The graft was divided and resected up to the proximal anastomosis.
The previous felt cuff was removed completely. The aorta was dissected free at this level to allow closure. This was done using interrupted 3-0 Prolene sutures in 3 layers. The left common iliac artery was then ligated. The entire prosthetic was removed. Due to the swollen turgidity of his gallbladder and potential for gallbladder related complications, I performed an open cholecystectomy. The right hepatorenal bypass was widely patent with a nice graft pulse. The left kidney was sacrificed. The abdomen was left open and covered with an ABThera suction device.
DESCRIPTION OF PROCEDURE: After obtaining informed consent from his wife, the patient was brought to the operating room and intubated. He was in acute renal failure and the continuous renal replacement therapy was discontinued in the ICU. Antibiotics were given. A timeout was completed. The patient was positioned supine. The legs, abdomen and chest were then prepped and draped in standard sterile fashion. Working in teams, the left axillary artery was exposed via a standard infraclavicular approach. Dissection was carried down through the skin and soft tissue.
Entry to the deeper space was accmplished between fibers of the pectoralis major muscle. Pectoralis minor muscle was divided at its insertion. The cephalic vein was ligated between silk ties and the axillary artery was exposed and encircled with umbilical tape. The previous longitudinal left femoral incision was reopened and vascular structures re-exposed. This revealed the common femoral artery with the cryo-preserved superficial femoral vein femoral-femoral bypass. The external iliac and inferior epigastric, superficial circumflex femoral arteries were all encircled with vessel loops.
A tunnel was created and an 8 mm ringed PTFE graft was tunneled below the level of the pectoralis minor muscle. Ten thousand units of heparin were given; ACT confirmed to be in the 250 to 300 range.
Clamps were placed on the axillary artery. Longitudinal arteriotomy was created. The graft was spatulated and a running 5-0 Prolene anastomosis was performed. Co-Seal was administered. Hemostasis appeared to be good.
We then focused our attention to the distal anastomosis. Clamps were placed proximally and distally. A longitudinal arteriotomy was created. The graft was cut to length, spatulated and an accessory running 6-0 Prolene anastomosis completed. Prior to completion, the vessels were flushed and the graft was deaired. Upon completion, hemostasis was good. There was a nice graft pulse. Following assurance of hemostasis, wounds were closed in layers using interrupted 2-0 and 3-0 Vicryl suture and Dermabond.
At this point, the wounds were kept covered. The abdominal ABThera device was removed. This revealed the massively distended colon and viscera. This was placed in a bowel bag. The hepatorenal bypass was checked and had a nice pulse. The abdominal contents were then rotated to expose the previously dissected aortic structures. All vessel loops were sorted out again. Additional bolus of heparin was given. The superior mesenteric artery was controlled with a Rumel loop. A DeBakey aortic clamp was placed at the level of the infraceliac aorta. The external and internal iliac arteries were secured with hypogastric clamps.
The capsule was then entered. The main body graft was visible. There was frank pus and slime all around it. This was sent for culture. The capsule was opened, graft was divided and dissection carried up to the proximal anastomosis. Ultimately, the tissue surrounding the previous graft and all the prosthetic material was removed. The entire felt pledget was dissected free. The quality of the aorta here was moderate. The left renal artery was sacrificed.
The aorta and capsule surrounding this area were freed to provide closure of the aortic stump. This was accomplished using interrupted 3-0 Prolene sutures in 3 longitudinal rows of U stitches. Following completion of this, hemostasis was good. Clamps were removed and flow restored to the superior mesenteric artery. There was a palpable pulse and a strong Doppler signal in the artery.
We then focused our attention removing the remainder of the graft. The anastomosis to the left common iliac artery was removed in its entirety. At this point, the left common iliac artery was oversewn with 3-0 Prolene suture and 0 silk ties. Clamps were removed off the external and internal iliac arteries. There was a good pulse at the level of the iliac bifurcation with preservation of the left hypogastric artery. Following this, the capsule was mechanically debrided but not frankly resected. The wound was reinspected for hemostasis, which was adequate.
Attention was then focused back over to the right side of the abdomen. The gallbladder was identified. The peritoneal attachments of the gallbladder were taken down in a top down fashion. The cystic artery was identified and ligated between silk ties. Dissection proceeded down to the cystic duct and the entire gallbladder was dangling freely off of this. We then divided it and oversewn it with 3-0 Maxon suture. This specimen was sent to pathology.
With this complete, the hepatorenal bypass was reinspected and again still had a nice palpable pulse. Two 10 French fluted Blake drains were placed in the abdomen, one in the cavity of the aortic capsule and then an additional drain in the left upper quadrant near the pancreatic tail. A tongue of omentum was freed and placed down in the retroperitoneum in the resection bed. The abdominal contents were then placed back in their normal positions and a new ABThera device was applied over the open wound.
At the end of this, he had an existing left internal jugular Mahurkar dialysis catheter and right internal jugular Cordis catheter. New clean drapes were placed and these were exchanged under sterile conditions using Seldinger technique to a left internal jugular triple-lumen catheter and a right internal jugular Trialysis catheter.
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