MEZIESKY
Guru
Help please, I stumped on this one. Need some kind of repair codes. Thank you.
- laceration of anal canal wall at 10:00 position....2.5 cm wide (involving
external and internal anal sphincters) and from anal verge and extending 4 cm
deep
- 1.5 x 0.5 cm central anterior rectal wall full thickness piercing
- traumatic rectovaginal fistula (methylene blue in rectum is present on cotton
swab in vagina)
PROCEDURE NAME:
Rectal examination under anesthesia
Anal rectal washout
Methylene blue test by instilling methylene blue and rectum and visualizing
methylene blue on cotton swab placed in vagina
Primary oversewing of anterior rectal wall
Primary oversewing/approximation of lateral anal wall sphincters at 10 o'clock
position
Packing of subcutaneous wound of anal wall at 10 o'clock position (lateral to
anal sphincters)
Foley catheter placement
INDICATIONS FOR PROCEDURE: 73 yo female with advanced Alzheimer's dementia fell
yesterday, landing on an upside down TV table leg which appears to her perianal
area. She is brought to the operating room for anorectal exploration and
treatment.
INTRA-OPERATIVE FINDINGS:
- laceration of anal canal wall at 10:00 position....2.5 cm wide (involving
external and internal anal sphincters) and from anal verge and extending 4 cm
deep
- 1.5 x 0.5 cm central anterior rectal wall full thickness piercing
- traumatic rectovaginal fistula (methylene blue in rectum is present on cotton
swab in vagina)
SPECIMEN: None
ANESTHESIA: General endotracheal
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and administered general anesthesia
by the anesthesia service. She was positioned prone jackknife position. The
perianal area was prepped and draped in usual sterile fashion and the butt
cheeks were separated using Mastisol and silk tape. A timeout was performed
identifying the patient, nature of procedure and any special equipment needed
for the operation. Preoperative prophylactic antibiotics were administered.
The perianal area was evaluated and an obvious full-thickness tear through the
anal sphincter muscles (internal and external) at the 10 o'clock position was
identified, extending from the anal verge to 4 cm deep. The anal verge the
laceration measured 2.5 cm. The anal canal and rectum were washed out to enable
better visualization. At that point it became obvious that there was an
additional puncture wound of the anterior wall. Exploration of the area and the
vagina did not demonstrate a clear communication between the rectum and the
vagina but the posterior vaginal wall was clearly visible through the opening
and the anterior rectal wall which measured 1.5 x 0.5 cm. A cotton swab was
placed in the vaginal vault and methylene blue was placed in the rectum.
Methylene blue was found to accumulate on the cotton swab, suggesting a
traumatic rectovaginal fistula which is likely small.
Due to the patient's severe dementia with combativeness and extreme difficulty
in caring for, the decision was made to avoid colostomy placement if at all
possible. With that, the decision was made for primary repair of the rectal
tear and the anal canal sphincter laceration. The anterior rectal wall was
reapproximated with full-thickness 4 0 Vicryl interrupted sutures and the anal
canal sphincter muscles were reapproximated with 3 0 Vicryl interrupted sutures.
The remaining anal subcutaneous wound lateral to the anal sphincters was packed
with quarter inch iodoform gauze. An ABD was applied over the anus. A Foley
catheter was then placed. The patient was sent to recovery area in stable
condition.
- laceration of anal canal wall at 10:00 position....2.5 cm wide (involving
external and internal anal sphincters) and from anal verge and extending 4 cm
deep
- 1.5 x 0.5 cm central anterior rectal wall full thickness piercing
- traumatic rectovaginal fistula (methylene blue in rectum is present on cotton
swab in vagina)
PROCEDURE NAME:
Rectal examination under anesthesia
Anal rectal washout
Methylene blue test by instilling methylene blue and rectum and visualizing
methylene blue on cotton swab placed in vagina
Primary oversewing of anterior rectal wall
Primary oversewing/approximation of lateral anal wall sphincters at 10 o'clock
position
Packing of subcutaneous wound of anal wall at 10 o'clock position (lateral to
anal sphincters)
Foley catheter placement
INDICATIONS FOR PROCEDURE: 73 yo female with advanced Alzheimer's dementia fell
yesterday, landing on an upside down TV table leg which appears to her perianal
area. She is brought to the operating room for anorectal exploration and
treatment.
INTRA-OPERATIVE FINDINGS:
- laceration of anal canal wall at 10:00 position....2.5 cm wide (involving
external and internal anal sphincters) and from anal verge and extending 4 cm
deep
- 1.5 x 0.5 cm central anterior rectal wall full thickness piercing
- traumatic rectovaginal fistula (methylene blue in rectum is present on cotton
swab in vagina)
SPECIMEN: None
ANESTHESIA: General endotracheal
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and administered general anesthesia
by the anesthesia service. She was positioned prone jackknife position. The
perianal area was prepped and draped in usual sterile fashion and the butt
cheeks were separated using Mastisol and silk tape. A timeout was performed
identifying the patient, nature of procedure and any special equipment needed
for the operation. Preoperative prophylactic antibiotics were administered.
The perianal area was evaluated and an obvious full-thickness tear through the
anal sphincter muscles (internal and external) at the 10 o'clock position was
identified, extending from the anal verge to 4 cm deep. The anal verge the
laceration measured 2.5 cm. The anal canal and rectum were washed out to enable
better visualization. At that point it became obvious that there was an
additional puncture wound of the anterior wall. Exploration of the area and the
vagina did not demonstrate a clear communication between the rectum and the
vagina but the posterior vaginal wall was clearly visible through the opening
and the anterior rectal wall which measured 1.5 x 0.5 cm. A cotton swab was
placed in the vaginal vault and methylene blue was placed in the rectum.
Methylene blue was found to accumulate on the cotton swab, suggesting a
traumatic rectovaginal fistula which is likely small.
Due to the patient's severe dementia with combativeness and extreme difficulty
in caring for, the decision was made to avoid colostomy placement if at all
possible. With that, the decision was made for primary repair of the rectal
tear and the anal canal sphincter laceration. The anterior rectal wall was
reapproximated with full-thickness 4 0 Vicryl interrupted sutures and the anal
canal sphincter muscles were reapproximated with 3 0 Vicryl interrupted sutures.
The remaining anal subcutaneous wound lateral to the anal sphincters was packed
with quarter inch iodoform gauze. An ABD was applied over the anus. A Foley
catheter was then placed. The patient was sent to recovery area in stable
condition.