Tammy Hale
Guest
- Messages
- 16
- Best answers
- 0
Hello. Sorry this is so long but wanted to include what I thought was important. Please help with coding suggestions. I found take down of splenic flexure but only when in adidtion to colectomy, which was not done. It looks like the main procedure was repair of the wound. Is that 13100? I do not have the measurement for repair.
This patient was stabbed and taken to OR for the following dictated procedures: 1) laparoscopy with emergency open laparotomy, 2) take down of splenic flexure and 3) evacuation of hemoperitoneum. In the dictation it says: There was no injury to the stomach. The lesser sac was opened and a small hole was found within the omentum. Lesser sac was explored and some adhesions were taken down but no retroperitoneal hematoma was seen. The splenic flexure of the colon was taken down to inspect the colon. This all looked good. The bowel was ran without injury to the bowel.
The hole in the posterior fascia was then closed using 1-0 PDS in a
figure-of-eight. The wound continued to ooze. The wound was then opened
up. We then extended the wound into the midline incision to get down to
the muscle. Hemorrhaging was controlled with Bovie cautery. The abdomen
was then irrigated out. There were no other signs of bleeding. The fascia
was closed using a 1-0 looped PDS from above and below and tied in the
middle. Skin was closed using staples.
THANK YOU!!!
This patient was stabbed and taken to OR for the following dictated procedures: 1) laparoscopy with emergency open laparotomy, 2) take down of splenic flexure and 3) evacuation of hemoperitoneum. In the dictation it says: There was no injury to the stomach. The lesser sac was opened and a small hole was found within the omentum. Lesser sac was explored and some adhesions were taken down but no retroperitoneal hematoma was seen. The splenic flexure of the colon was taken down to inspect the colon. This all looked good. The bowel was ran without injury to the bowel.
The hole in the posterior fascia was then closed using 1-0 PDS in a
figure-of-eight. The wound continued to ooze. The wound was then opened
up. We then extended the wound into the midline incision to get down to
the muscle. Hemorrhaging was controlled with Bovie cautery. The abdomen
was then irrigated out. There were no other signs of bleeding. The fascia
was closed using a 1-0 looped PDS from above and below and tied in the
middle. Skin was closed using staples.
THANK YOU!!!