bmanus
Guru
Any suggestions for the CPT codes?
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room
and after patient identification and procedural verification he
underwent general orotracheal anesthesia and was invasively monitored
and kept supine on the operating table with 30 degree left side up and
his arm being placed at 45 degrees abduction. He was then prepped and
draped. His prior supraclavicular skin scar was incised and the
pectoralis myocutaneous flap was raised by elevating the flap from the
clavicle with electrocautery. The phlegmon was primarily at the prior
site of the clavicular head. The manubrium was encountered and
skeletonized with electrocautery and the medial skin incision of the
L-shaped surgical approach was carried down to the inferior third of the
sternum. The pectoralis was then elevated from the ribs to the mid
axillary line, keeping the pectoralis minor onto the chest cage and
using electrocautery to have meticulous hemostasis. The area of the
prior surgery had an unexpectedly large phlegmon which was fistulized
and serpiginously involved the manubrium, the subclavicular space up to
the 1st rib down to the superior border of the 2nd rib. The clavicle
was dissected out to the lateral third where it was circumferentially
dissected sharply. The manubrium was skeletonized and the entire
infected field was skeletonized after this was cultured. Careful
dissection was made at the area of the clavicle to avoid the internal
jugular vein as well as the thoracic duct and this was done sharply.
Once the subclavicular space entered, I was able to bluntly dissect the
pleura from the specimen. The substernal space was similarly dissected
with my finger and a right angled incision was made from the
suprasternal notch down to the 1st intercostal space with an oscillating
saw, removing the left hemi-manubrium. The junction of the medial and
lateral third of the clavicle was then divided with an oscillating saw
and the infected bone flap was then raised down to and including the
medial left 1st rib. The flap was inclusive ultimately of a small
portion of the pleura underneath the 1st rib. The internal mammary was
dissected free from the flap and multiple 5-0 Prolene suture ligatures
were used for mammary branches. Once the infected tissue was removed
with the thin skin kept adherent to the surgical specimen to get back to
excellent dermally normal skin, the wound was flushed with 1 liter of
bacitracin solution. This was aspirated. The entry into the pleural
space involved an injury to the lung, which was then Pro Gel sealed and
drained, specifically with a #7 flat Axiom drain placed medially and
secured to the skin with suture. We had excellent redundancy to the
pectoralis myocutaneous advancement flap. A great deal of time was
spent obtaining pinpoint hemostasis throughout the entire flap as well
as the chest wall and remaining bone fragments of the lateral clavicle,
the lateral 1st rib and the remaining sternal body and right
hemi-manubrium. The pectoralis fascia was then sewn to the superficial
cervical fascia superiorly as well as the clavipectoral fascia of the
right medially after an additional flat axiom 7 mm drain was placed
underneath the flap. The skin was then closed with multiple vertical
mattress sutures of 3-0 silk and the patient was awakened, extubated,
and transferred to the postanesthesia care unit with correct sponge,
needle and instrument counts, suffering no apparent complications from
the surgery.
_________________________________________
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room
and after patient identification and procedural verification he
underwent general orotracheal anesthesia and was invasively monitored
and kept supine on the operating table with 30 degree left side up and
his arm being placed at 45 degrees abduction. He was then prepped and
draped. His prior supraclavicular skin scar was incised and the
pectoralis myocutaneous flap was raised by elevating the flap from the
clavicle with electrocautery. The phlegmon was primarily at the prior
site of the clavicular head. The manubrium was encountered and
skeletonized with electrocautery and the medial skin incision of the
L-shaped surgical approach was carried down to the inferior third of the
sternum. The pectoralis was then elevated from the ribs to the mid
axillary line, keeping the pectoralis minor onto the chest cage and
using electrocautery to have meticulous hemostasis. The area of the
prior surgery had an unexpectedly large phlegmon which was fistulized
and serpiginously involved the manubrium, the subclavicular space up to
the 1st rib down to the superior border of the 2nd rib. The clavicle
was dissected out to the lateral third where it was circumferentially
dissected sharply. The manubrium was skeletonized and the entire
infected field was skeletonized after this was cultured. Careful
dissection was made at the area of the clavicle to avoid the internal
jugular vein as well as the thoracic duct and this was done sharply.
Once the subclavicular space entered, I was able to bluntly dissect the
pleura from the specimen. The substernal space was similarly dissected
with my finger and a right angled incision was made from the
suprasternal notch down to the 1st intercostal space with an oscillating
saw, removing the left hemi-manubrium. The junction of the medial and
lateral third of the clavicle was then divided with an oscillating saw
and the infected bone flap was then raised down to and including the
medial left 1st rib. The flap was inclusive ultimately of a small
portion of the pleura underneath the 1st rib. The internal mammary was
dissected free from the flap and multiple 5-0 Prolene suture ligatures
were used for mammary branches. Once the infected tissue was removed
with the thin skin kept adherent to the surgical specimen to get back to
excellent dermally normal skin, the wound was flushed with 1 liter of
bacitracin solution. This was aspirated. The entry into the pleural
space involved an injury to the lung, which was then Pro Gel sealed and
drained, specifically with a #7 flat Axiom drain placed medially and
secured to the skin with suture. We had excellent redundancy to the
pectoralis myocutaneous advancement flap. A great deal of time was
spent obtaining pinpoint hemostasis throughout the entire flap as well
as the chest wall and remaining bone fragments of the lateral clavicle,
the lateral 1st rib and the remaining sternal body and right
hemi-manubrium. The pectoralis fascia was then sewn to the superficial
cervical fascia superiorly as well as the clavipectoral fascia of the
right medially after an additional flat axiom 7 mm drain was placed
underneath the flap. The skin was then closed with multiple vertical
mattress sutures of 3-0 silk and the patient was awakened, extubated,
and transferred to the postanesthesia care unit with correct sponge,
needle and instrument counts, suffering no apparent complications from
the surgery.
_________________________________________