Hi!!
I need help with coding this general surgery op report:
INDICATIONS: 82 YO MALE W/HX OF BLADDER RESECTION AND NEOBLADDER CREATION W/SUBSEQUENT PARASTOMAL HERNIA DISCOVERY AND REPAIR USING BIO MESH. SUBSEQUENTLY, THE PT HAS DEVELOPED DYSURIA IN THE FORM OF UTI REPORTEDLY SECONDARY TO DIFFICULTY OF URINE BEING EXPRESSED FROM HIS UROSTOMY.
PROCEDURE: Exploration of Abdominal wall
DETAIL: After successful LMA placement, the patient's abdomen was prepped and draped in the usual sterile fashion. We digitally examined the urostomy, an area of narrowing presumably at the level of the fascia was noted, most notably in the inferior aspect. We then approached that area from a separate 3 cm incision and approx 2 cm inferior to the urostomy site. We extended the incision into the subcutaneous tissue using the Bovie cautery as well into the anterior and posterior fascia. We opened both fascial levels and subsequently noticed that the urine was free floating from the urostomy. Any further exploration into the abdominal cavity could have potentially injured the urostomy and as a result was avoided. Hemostasis was ascertained. The incision was irrigated and was closed using multiple interrupted 3-0 Vicryl sutures to reapproximate subcutaneous tissue and skin was closed using a running intracuticular interlocking PDS suture followed by application of skin glue.
All opinions appreciated!!
I need help with coding this general surgery op report:
INDICATIONS: 82 YO MALE W/HX OF BLADDER RESECTION AND NEOBLADDER CREATION W/SUBSEQUENT PARASTOMAL HERNIA DISCOVERY AND REPAIR USING BIO MESH. SUBSEQUENTLY, THE PT HAS DEVELOPED DYSURIA IN THE FORM OF UTI REPORTEDLY SECONDARY TO DIFFICULTY OF URINE BEING EXPRESSED FROM HIS UROSTOMY.
PROCEDURE: Exploration of Abdominal wall
DETAIL: After successful LMA placement, the patient's abdomen was prepped and draped in the usual sterile fashion. We digitally examined the urostomy, an area of narrowing presumably at the level of the fascia was noted, most notably in the inferior aspect. We then approached that area from a separate 3 cm incision and approx 2 cm inferior to the urostomy site. We extended the incision into the subcutaneous tissue using the Bovie cautery as well into the anterior and posterior fascia. We opened both fascial levels and subsequently noticed that the urine was free floating from the urostomy. Any further exploration into the abdominal cavity could have potentially injured the urostomy and as a result was avoided. Hemostasis was ascertained. The incision was irrigated and was closed using multiple interrupted 3-0 Vicryl sutures to reapproximate subcutaneous tissue and skin was closed using a running intracuticular interlocking PDS suture followed by application of skin glue.
All opinions appreciated!!