Wiki Cranial Vault Reconstruction

mireya77

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Any coders with experience in this type of coding, your help would be greatly appreciated:
CF surgeon wants to bill 61559 and 62147
NS surgeon wants to bill 61559 and 61556

CF op note:
POSTOPERATIVE DIAGNOSIS:
Left unilateral lambdoid synostosis.

PROCEDURE:
1. Reconstruction of posterior 2/3 cranium with barrel staves recontouring and
multiple osteotomies.
2. Autogenous cranioplasty 9 square centimeters.
HISTORY OF PRESENT ILLNESS:
The patient is a 10-month-old with unicoronal synostosis. She was diagnosed and
evaluated in the craniofacial center and the risks and benefits of surgical
intervention were discussed in detail with the mom.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed in supine position. After
adequate general endotracheal anesthesia was established, we wired the tube,
placed Tegaderms over the eyes, padded the face and then put her in the prone
position, with adequate padding and protection. We infiltrated a zigzag
bicoronal incision with 1/8% Lidocaine with epinephrine. After adequate time
elapsed for epinephrine effect and a standard prep and drape, we made the
incision, raised the flaps anteriorly and posteriorly in the subgaleal plane,
raised up the pericranium as a separate flap. We then dissected all the way
back past the superior and inferior nuchal lines, foramen magnum, called in NS surgeon. He did an osteotomy of the biparietal area and occiput, he will dictate
that under his cover. He then did some barrel staves at the base of skull and
then scrubbed out.

We then did barrel staving on the right side with outfracturing. We used
Tessier bone benders to recontour the base of the skull as well as the
outfractured barrel staves on the left parietal area, and then recontoured the
occipital bone with Tessier bone benders, created some osteotomies there. We
then harvested a bone graft using a craniotome from the right parietal area to
help us stabilize the reconstruction. We offset the posterior fossa, advancing
the left side posteriorly more than the right side. We secured it with implants
KLS Martin resorbable system, and then used interposition bone grafting to help
stabilize everything. We then washed out copiously, closed the galea with
Vicryl, placed drains in the subgaleal space and then secured them with
independent sutures. Washed out one more time, closed, used 2-0 Vicryl in the
skin, 4-0 Vicryl in the galea, removed the 2-0 Vicryls, then replaced with a 5-0
chromic. At the end of procedure, the patient was extubated in the operating
room and transferred to the intensive care unit in stable condition without
complication.

NS op note:
OPERATION:
Occipital craniotomy, multiple barrel stave osteotomies for posterior cranial
vault reconstruction.
NARRATIVE SUMMARY:
After smooth induction of general endotracheal anesthesia, the patient was
turned to the prone position, all pressure points well-padded. He was then
prepped and draped in the usual manner. The initial opening was done by CF surgeon. We performed a bilateral zigzag incision and then harvested
vascularized pericranial flaps. I then drilled a trough just more rostral to
the lambda and then another trough just below the inion. Another trough was
made by the asterion bilaterally. Then, I was able to turn the suboccipital
bone flap. The bone was quite thin and the dura was under some pressure where
we were to expose the torcula, the transverse sinuses along with the sagittal
sinus without any evidence of tears or bleeding. We then made multiple barrel
stave osteotomies in the suboccipital bone and also in the left parietal bone
for outfracturing. The case was at this point turned over to CF surgeon for
completion of the reconstruction and he will dictate that portion in his own
operative procedure. The patient tolerated this portion of the procedure well.
 
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