Desperate Denise
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Hi guys!!
I would really appreciate it if you would help me code this operative report. There is a labral debridement, arthroscopically assisted subpectoralis tenodesis, bursectomy, subacromial decompression.
Please see the operative report below.
PREOPERATIVE DIAGNOSIS: Left shoulder biceps labral complex tear and
impingement syndrome.
POSTOPERATIVE DIAGNOSIS: Left shoulder biceps labral complex tear and
impingement syndrome.
PROCEDURE: Left shoulder diagnostic arthroscopy with arthroscopically assisted subpectoral
tenodesis and subacromial decompression.
ANESTHESIA: General.
INDICATIONS: The patient is a 50-year-old who has complaints of pain in
his left shoulder with failed conservative measures. MRI showing type 2
SLAP tear. There is bony type 3 acromion. Risks and benefits were
discussed and he wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating room table. After induction of general anesthetic of interscalene block, he was placed in a beach chair position. All bony prominences were padded. Left shoulder was prepped and draped in the standard surgical fashion. Posterior portal was created. Subscapularis was intact. Articular surfaces were normal. Supraspinatus and rotator cuff were normal articularly. Biceps tendon had normal integrity except at the attachment site where there was a large tear of the superior labrum with extension anteriorly and posteriorly. A labral debridement was carried out. Biceps was resected and allowed to slip into the groove. Attention was directed to the subacromial space where a subacromial decompression was carried out for a large acromial spur.
Rotator cuff was intact from above. Bursectomy was carried out. A subpectoral incision was then carried out. Dissection was carried down through skin and subcutaneous tissue. Biceps tendon was viewed. The tendon was resected and a 5.5 Arthrex corkscrew anchor was placed in the humerus. The tendon was whipstitched with 2 sutures and tied down securely with excellent tension on the biceps. The incisions were irrigated and closed with 2-0 Vicryl and 4-0 Monocryl. Steri-Strips and dry sterile dressing were applied. The patient tolerated the procedure well and
returned to recovery in stable condition.
I would really appreciate it if you would help me code this operative report. There is a labral debridement, arthroscopically assisted subpectoralis tenodesis, bursectomy, subacromial decompression.
Please see the operative report below.
PREOPERATIVE DIAGNOSIS: Left shoulder biceps labral complex tear and
impingement syndrome.
POSTOPERATIVE DIAGNOSIS: Left shoulder biceps labral complex tear and
impingement syndrome.
PROCEDURE: Left shoulder diagnostic arthroscopy with arthroscopically assisted subpectoral
tenodesis and subacromial decompression.
ANESTHESIA: General.
INDICATIONS: The patient is a 50-year-old who has complaints of pain in
his left shoulder with failed conservative measures. MRI showing type 2
SLAP tear. There is bony type 3 acromion. Risks and benefits were
discussed and he wished to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating room table. After induction of general anesthetic of interscalene block, he was placed in a beach chair position. All bony prominences were padded. Left shoulder was prepped and draped in the standard surgical fashion. Posterior portal was created. Subscapularis was intact. Articular surfaces were normal. Supraspinatus and rotator cuff were normal articularly. Biceps tendon had normal integrity except at the attachment site where there was a large tear of the superior labrum with extension anteriorly and posteriorly. A labral debridement was carried out. Biceps was resected and allowed to slip into the groove. Attention was directed to the subacromial space where a subacromial decompression was carried out for a large acromial spur.
Rotator cuff was intact from above. Bursectomy was carried out. A subpectoral incision was then carried out. Dissection was carried down through skin and subcutaneous tissue. Biceps tendon was viewed. The tendon was resected and a 5.5 Arthrex corkscrew anchor was placed in the humerus. The tendon was whipstitched with 2 sutures and tied down securely with excellent tension on the biceps. The incisions were irrigated and closed with 2-0 Vicryl and 4-0 Monocryl. Steri-Strips and dry sterile dressing were applied. The patient tolerated the procedure well and
returned to recovery in stable condition.