rockylopez
Networker
Hello fellow coders. I am trying to make sure I get this op report correctly. Patient had a csection same day and had to return back to OR for exp lap with additional procedure for subfascial hematoma after csection. Can someone please confirm if this should be 49002 with mod 78??
OPERATIVE PROCEDURE NOTE
PREOPERATIVE DIAGNOSES:
1. WOUND HEMATOMA
2. ECLAMPSIA
3. THROMBOCYTOPENIA
4. S/P CESAREAN SECTION
POSTOPERATIVE DIAGNOSES:
1. SUBFASCIAL HEMATOMA
2. ECLAMPSIA
3. THROMBOCYTOPENIA
4. S/P CESAREAN SECTION
NAME OF PROCEDURE: EXPLORATORY LAPAROTOMY; EVACUATION OF SUBFASCIAL HEMATOMA WITH HEMOSTATIC ELECTROCAUTERY/PLACEMENT OF HEMOSTATIC SUTURES AND SURGICEL HEMOSTATIC POWER; PLACEMENT OF DRAIN OVER MUSCLE
ANESTHESIA: GENERAL
QUANTIFIED BLOOD LOSS: 537 mL (~500 mL Blood clots)
FINDINGS: There were blood clots in the superficial wound bed, but no definitve bleeding vessel was identified. Upon entry into the fascial layer, there was approximately 500 mL of blood clots diffusely spread over the rectus abdominus muscles which were evacuated. There was no evidence of a bleeding vessel but the rectus abdominus muscles continued to diffusely ooze blood throughout the procedure. There were no blood clots or significant blood noted in the peritoneal cavity. The uterine hysterotomy incision was intact and there was no evidence of bleeding at the suture line. The ovaries and fallopian tubes were normal in appearance bilaterally and without any evidence of bleeding. The bladder appeared normal and without any bleeding. Bladder integrity was confirmed via a sterile milk test.
COMPLICATIONS: None.
DRAINS: Foley catheter; UOP ~ 35 mL, yellow
SPECIMENS: None
COUNTS: Correct x2.
DVT PROPHYLAXIS: SCDs in place and the onset of the case
PREOPERATIVE ANTIBIOTICS: Mefoxin 2 grams
INDICATIONS FOR PROCEDURE:
The patient's surgical bandage was noted to have a large amount of staining. With removal of the bandage, it was noted to be saturated with blood. There were several small clots along the suture line, as well as, a small amount of bleeding from the left margin of the incision. There was a firm, tender area above the left incision margin. Additionally, the patient abdomen appeared to be distended. There was suspicion of a wound hematoma.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken back to the operating room where she was placed in a supine position and general anesthesia was administered. The patient was then prepped and draped in the usual fashion for an abdominal procedure.
The Insorb staples in the Pfannenstiel skin incision were cut open using the Mayo scissors. Immediately, the wound bed was noted to have minimal amount of blood clots which were evacuated. An exploration of the wound bed did not identify a bleeding vessel. The fascial suture was cut open and blood clots were noted diffusely across the rectus abdominis muscles, which were evacuated. The peritoneal cavity was entered and appeared dry and free of any blood or blood clots. However the uterus was exteriorized and the uterine hysterotomy incision was intact and without any evidence of bleeding. The adnexa were inspected and noted to be completely normal.
The bladder was inspected and appeared to be normal, intact and without any evidence of bleeding. Of note, in the patient's cesarean section procedure, she was noted to have a small amount of blood in her urine. The urine output during the cesarean section procedure was approximately 30 cc but was slightly blood-tinged. As the abdomen was closed, the patient was scheduled to have a cystogram to check bladder integrity. However the decision was made to do a bladder integrity test during this procedure. The bladder was filled with approximately 100 mL of sterile milk via the Foley catheter. There was no evidence of spillage of the sterile milk into the surgical field confirming bladder integrity. The uterus was then returned to the abdomen.
Attention was turned to the rectus abdominis muscles which appeared to be diffusely oozing blood. At this point, the largest areas of oozing were cauterized and a few areas which were still oozing after cautery were hemostatically sutured with a figure-of-eight stitch of 2-0 chromic to achieve excellent hemostasis. Following this, Surgicel powder was sprinkled over the rectus abdominis muscles. Good hemostasis was noted.
Then, a JP drain was placed over the rectus abdominis muscles and the drain tubing was brought out through an incision in the right lower quadrant of the abdomen and then attached to the suction cup.
Attention was then turned to closure of the abdomen. The fascia was then reapproximated with a continuous running stitch of #1–STRATAFIX. The subcutaneous tissues were reapproximated with a continuous running stitch of 2-0 plain gut and the skin was closed with metal staples. All layers were fairly hemostatic at the time of closure. Then, using a silk suture, the tubing of the JP drain was fixed into place.
The procedure was then terminated. All instrument, needle, sponge and lap counts were correct X 2. The patient tolerated the procedure well and was transferred to the recovery area in stable condition.
OPERATIVE PROCEDURE NOTE
PREOPERATIVE DIAGNOSES:
1. WOUND HEMATOMA
2. ECLAMPSIA
3. THROMBOCYTOPENIA
4. S/P CESAREAN SECTION
POSTOPERATIVE DIAGNOSES:
1. SUBFASCIAL HEMATOMA
2. ECLAMPSIA
3. THROMBOCYTOPENIA
4. S/P CESAREAN SECTION
NAME OF PROCEDURE: EXPLORATORY LAPAROTOMY; EVACUATION OF SUBFASCIAL HEMATOMA WITH HEMOSTATIC ELECTROCAUTERY/PLACEMENT OF HEMOSTATIC SUTURES AND SURGICEL HEMOSTATIC POWER; PLACEMENT OF DRAIN OVER MUSCLE
ANESTHESIA: GENERAL
QUANTIFIED BLOOD LOSS: 537 mL (~500 mL Blood clots)
FINDINGS: There were blood clots in the superficial wound bed, but no definitve bleeding vessel was identified. Upon entry into the fascial layer, there was approximately 500 mL of blood clots diffusely spread over the rectus abdominus muscles which were evacuated. There was no evidence of a bleeding vessel but the rectus abdominus muscles continued to diffusely ooze blood throughout the procedure. There were no blood clots or significant blood noted in the peritoneal cavity. The uterine hysterotomy incision was intact and there was no evidence of bleeding at the suture line. The ovaries and fallopian tubes were normal in appearance bilaterally and without any evidence of bleeding. The bladder appeared normal and without any bleeding. Bladder integrity was confirmed via a sterile milk test.
COMPLICATIONS: None.
DRAINS: Foley catheter; UOP ~ 35 mL, yellow
SPECIMENS: None
COUNTS: Correct x2.
DVT PROPHYLAXIS: SCDs in place and the onset of the case
PREOPERATIVE ANTIBIOTICS: Mefoxin 2 grams
INDICATIONS FOR PROCEDURE:
The patient's surgical bandage was noted to have a large amount of staining. With removal of the bandage, it was noted to be saturated with blood. There were several small clots along the suture line, as well as, a small amount of bleeding from the left margin of the incision. There was a firm, tender area above the left incision margin. Additionally, the patient abdomen appeared to be distended. There was suspicion of a wound hematoma.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken back to the operating room where she was placed in a supine position and general anesthesia was administered. The patient was then prepped and draped in the usual fashion for an abdominal procedure.
The Insorb staples in the Pfannenstiel skin incision were cut open using the Mayo scissors. Immediately, the wound bed was noted to have minimal amount of blood clots which were evacuated. An exploration of the wound bed did not identify a bleeding vessel. The fascial suture was cut open and blood clots were noted diffusely across the rectus abdominis muscles, which were evacuated. The peritoneal cavity was entered and appeared dry and free of any blood or blood clots. However the uterus was exteriorized and the uterine hysterotomy incision was intact and without any evidence of bleeding. The adnexa were inspected and noted to be completely normal.
The bladder was inspected and appeared to be normal, intact and without any evidence of bleeding. Of note, in the patient's cesarean section procedure, she was noted to have a small amount of blood in her urine. The urine output during the cesarean section procedure was approximately 30 cc but was slightly blood-tinged. As the abdomen was closed, the patient was scheduled to have a cystogram to check bladder integrity. However the decision was made to do a bladder integrity test during this procedure. The bladder was filled with approximately 100 mL of sterile milk via the Foley catheter. There was no evidence of spillage of the sterile milk into the surgical field confirming bladder integrity. The uterus was then returned to the abdomen.
Attention was turned to the rectus abdominis muscles which appeared to be diffusely oozing blood. At this point, the largest areas of oozing were cauterized and a few areas which were still oozing after cautery were hemostatically sutured with a figure-of-eight stitch of 2-0 chromic to achieve excellent hemostasis. Following this, Surgicel powder was sprinkled over the rectus abdominis muscles. Good hemostasis was noted.
Then, a JP drain was placed over the rectus abdominis muscles and the drain tubing was brought out through an incision in the right lower quadrant of the abdomen and then attached to the suction cup.
Attention was then turned to closure of the abdomen. The fascia was then reapproximated with a continuous running stitch of #1–STRATAFIX. The subcutaneous tissues were reapproximated with a continuous running stitch of 2-0 plain gut and the skin was closed with metal staples. All layers were fairly hemostatic at the time of closure. Then, using a silk suture, the tubing of the JP drain was fixed into place.
The procedure was then terminated. All instrument, needle, sponge and lap counts were correct X 2. The patient tolerated the procedure well and was transferred to the recovery area in stable condition.
