KBean2018
Guru
Hello, I am trying to properly code a TRAM-FLAP. Would it be 19366-50 or 19367-50? Only coding for Tram Flap. thank you in advance!
A low suprapubic abdominal wall incision was made followed by a supraumbilical incision according to her preoperative markings. Cautery was used to dissect through the subcutaneous fat and scarpas fascia until the anterior rectus sheath fascia was identified. Proceeding from the right lateral corner towards the midline dissection continued medially above the fascia until the lateral row of periumbilical perforators was reached. The skin of her umbilicus was then circumferentially incised. The subcutaneous tissue was dissected carefully to keep the stalk well vascularized. I then dissected from the left lateral corner towards the midline again stopping at the lateral row of periumbilical perforators. I then incised to the anterior rectus sheath at the level of the right lateral row perforators. The right rectus muscle was identified and bluntly dissected off of the anterior rectus sheath distally until the right deep inferior epigastric vessels were identified. They were clipped and ligated. The muscle was then removed from the posterior rectus sheath bluntly. I then completed the left sided dissection by removing the skin and subcutaneous fat off of the anterior rectus sheath until I reached the midline at which point I incised the anterior rectus sheath so the fascia and right rectus muscle all went with the overlying skin flap. A subcutaneous tunnel was then created in the right subcutaneous space overlying the right anterior rectus sheath extending across the midline to reach the left chest defect. This was done using a lighted breast retractor and electrocautery. At this point Dr. had completed the left modified radical mastectomy had moved onto the right side. I then irrigated the abdomen with normal saline. 2 15 French JP drains were placed and secured with 4-0 nylon. The site of the neoumbilicus was confirmed and a circular skin defect was created. It was defatted to allow the umbilicus to be recessed in the skin flap. Scarpas fascia was reapproximated with figure of 8 2-0 Vicryl sutures. The dermis was closed with interrupted 3-0 Vicryl suture. A running subcuticular 4-0 Monocryl strata fix was used to close the skin. The umbilicus was inset with 3-0 Vicryl in the dermis and 4-0 Vicryl in the skin. The pedicle was examined and ensured that there was no kinking. The left chest and axilla were irrigated with normal saline. Hemostasis was achieved using cautery. A 15 French JP drain was placed in the axilla and a second was placed within the left chest wall defect. These were secured using 4-0 nylon. The right TRAM flap was inset into the left chest wall defect using 3-0 Vicryl sutures in the dermis and 4-0 Monocryl strata fix suture in the subcuticular layer. Dermabond prineo was placed over the incisions
A low suprapubic abdominal wall incision was made followed by a supraumbilical incision according to her preoperative markings. Cautery was used to dissect through the subcutaneous fat and scarpas fascia until the anterior rectus sheath fascia was identified. Proceeding from the right lateral corner towards the midline dissection continued medially above the fascia until the lateral row of periumbilical perforators was reached. The skin of her umbilicus was then circumferentially incised. The subcutaneous tissue was dissected carefully to keep the stalk well vascularized. I then dissected from the left lateral corner towards the midline again stopping at the lateral row of periumbilical perforators. I then incised to the anterior rectus sheath at the level of the right lateral row perforators. The right rectus muscle was identified and bluntly dissected off of the anterior rectus sheath distally until the right deep inferior epigastric vessels were identified. They were clipped and ligated. The muscle was then removed from the posterior rectus sheath bluntly. I then completed the left sided dissection by removing the skin and subcutaneous fat off of the anterior rectus sheath until I reached the midline at which point I incised the anterior rectus sheath so the fascia and right rectus muscle all went with the overlying skin flap. A subcutaneous tunnel was then created in the right subcutaneous space overlying the right anterior rectus sheath extending across the midline to reach the left chest defect. This was done using a lighted breast retractor and electrocautery. At this point Dr. had completed the left modified radical mastectomy had moved onto the right side. I then irrigated the abdomen with normal saline. 2 15 French JP drains were placed and secured with 4-0 nylon. The site of the neoumbilicus was confirmed and a circular skin defect was created. It was defatted to allow the umbilicus to be recessed in the skin flap. Scarpas fascia was reapproximated with figure of 8 2-0 Vicryl sutures. The dermis was closed with interrupted 3-0 Vicryl suture. A running subcuticular 4-0 Monocryl strata fix was used to close the skin. The umbilicus was inset with 3-0 Vicryl in the dermis and 4-0 Vicryl in the skin. The pedicle was examined and ensured that there was no kinking. The left chest and axilla were irrigated with normal saline. Hemostasis was achieved using cautery. A 15 French JP drain was placed in the axilla and a second was placed within the left chest wall defect. These were secured using 4-0 nylon. The right TRAM flap was inset into the left chest wall defect using 3-0 Vicryl sutures in the dermis and 4-0 Monocryl strata fix suture in the subcuticular layer. Dermabond prineo was placed over the incisions