I coded this with CPT 49020 & 11008, denied again on a 2nd level appeal. Am I missing something? Surgeon drained a deep retroperitoneal abscess and removed deep chronically infected mesh so I am at a loss. Any thoughts? TIA
PREOPERATIVE DIAGNOSES:
Retroperitoneal abscess and chronically infected mesh.
POSTOPERATIVE DIAGNOSES:
Retroperitoneal abscess and chronically infected mesh.
PROCEDURES:
Exploratory laparotomy, lysis of adhesions, drainage of peritoneal abscess and removal of chronically infected polypropy...
CLINICAL NOTE:
The patient is a 74-year-old female who underwent an open appendectomy for a perforated appendicitis. The patient subsequently developed an abscess after that procedure that resolved with a CT-guided drainage catheter. She subsequently developed an incisional hernia at that site. She had previously undergone a laparoscopic bilateral inguinal hernia repair as well as a laparoscopic umbilical hernia repair. In any case, she went to the operating room for a laparoscopic incisional hernia repair. This became infected and in 2017, she went back for laparotomy, drainage of an abscess and removal of the infected mesh. The patient convalesced quite well over the last 5 years and really did not have any problem until around Thanksgiving time when she developed some erythematous nodularity at the old right lower quadrant scar. This was drained in the office, but there was no significant purulence, no obvious foreign body. She subsequently underwent CT scan, which demonstrated an abscess cavity that tracked about 12 cm from the skin site all the way down to what appeared to be some potentially retained mesh. She comes to the OR today for exploration and removal.
OPERATIVE NOTE:
The patient was brought to the operating room suite and laid supine on the table, given general anesthetic. A Foley catheter was placed without incident. The abdomen was prepped with chlorhexidine and draped in the usual standard fashion. I made an elliptical incision around the lateral aspect of her appendectomy incision. This was then deepened down into the subcutaneous tissue, debriding any of the necrotic subcutaneous tissue and this was tracked all to be going below the fascia and we immediately identified a portion of the abscess cavity, which was subsequently drained out. I had already obtained cultures from her, had a previous incision and drainage in the office growing methicillin-sensitive Staph aureus and so no further cultures were really taken. At this point, we had a little bit more difficulty trying to get into the lower portion of the abscess cavity. We had not yet entered the abdomen at this point until it was a little difficult to know exactly where we are, but it was very clear that it was going to be difficult to do this through this roughly 6 cm transversely oriented incision and I thought rather than open up the entirety of the incision, I made a counter incision down to the lateral aspect of her C-section scar on the right side and I basically got into the same plane as the abscess cavity, which then allowed us to get further deeper into the abdominal wall. We could see the peritoneal layer. This was opened just below some very densely adherent small bowel to the upper portion of this dissection. At this point, we were able to see that more the right lower quadrant extending along the pelvic side wall was actually devoid of any adherent bowel or signs of infection and ultimately based on this, it became clear that this was a retroperitoneal or an extraperitoneal process at least more inferiorly. At this point, we spent some time lysing the adhesions of the small bowel to what was basically the intraperitoneal portion of the abscess cavity superiorly. This was done completely. There was probably just a 4 cm segment of the small bowel that was whose serosal surface was part of the abscess cavity. Once this was lysed, the whole right lower quadrant was really free. We inspected this loop of bowel. There was no full-thickness injury. It was hard to tell whether there is truly a serosal injury or whether there was just simply some of the abscess cavity on the serosa. This was trimmed away. It was inspected again. We imbricated some of the tissue over this area just in case there was truly a serosal tear in the area, but no full-thickness injury and no spillage of bile. A sponge was then placed to keep the bowel from getting into our way. The patient was also placed into Trendelenburg to assist with this. We had an instrument on the sponge for later retrieval. Once this portion of the abscess cavity had been actually opened up, we encountered a corner of the mesh and this part of the mesh was polypropylene, it was not at all incorporated into the tissue, just kind of free floating in this cavity and at first, this did not make a lot of sense since the thought was that she had intraperitoneal mesh that was infected and only partially removed at the time of her previous operation to remove infected mesh, but in reality that mesh was probably more fully removed. It just had seeded previously placed extraperitoneal laparoscopic inguinal mesh and only a portion of that mesh had been removed, probably leaving behind what looked to be incorporated at the time of that procedure, but ultimately it was contaminated leading to this outcome that this mesh that we found, we continued to follow this down using essentially blunt dissection with a peanut dissector, gently pulling on that mesh and trying to separate any of the surrounding tissue. We followed this down to 1 clear metallic fastener and that last little remnant of the mesh likely did pull-through the second fastener but we could tell by inspecting the mesh that the 3 sides were intact. It was just probably along the horizontal axis where you could see that the mesh had been essentially trimmed probably at the time of the previous procedure. This was handed off the field for gross evaluation. It was clearly polypropylene and it was clearly extraperitoneal. We inspected the abscess cavity. We palpated the region. There was significant induration. We did not see any other additional areas of mesh. At this point, the area was copiously irrigated. The peritoneal layer was closed to exclude the viscera after removing the previously placed 4 x 8 instruments. All sponge, needle and instrument counts were correct at this point. With the viscera excluded, we then laid in a #10 flat JP, which extended down to the bottom of this abscess cavity and then closed the fascia with a #1 PDS in a running fashion through the lower incision. The drain had been tunneled up. We were able to find the pinpoint communication between the lower connection and upper connection and that is where we guided the catheter through scar part. The drain was actually brought out through a separate stab incision even further laterally, sutured with a 2-0 nylon and then the fascial material was brought together with another #1 PDS through the upper incision. Any obvious necrotic chronically infected tissue was debrided. The purulence had all been removed as well as granulating tissue with copious irrigation and then finally ultimately the skin was closed loosely with skin clips. Dry dressings were applied. The Foley catheter was removed. Anesthesia service provided TAP block in this region. She was ultimately awoken from the anesthetic and returned to the PACU in stable condition having tolerated the procedure well.
PREOPERATIVE DIAGNOSES:
Retroperitoneal abscess and chronically infected mesh.
POSTOPERATIVE DIAGNOSES:
Retroperitoneal abscess and chronically infected mesh.
PROCEDURES:
Exploratory laparotomy, lysis of adhesions, drainage of peritoneal abscess and removal of chronically infected polypropy...
CLINICAL NOTE:
The patient is a 74-year-old female who underwent an open appendectomy for a perforated appendicitis. The patient subsequently developed an abscess after that procedure that resolved with a CT-guided drainage catheter. She subsequently developed an incisional hernia at that site. She had previously undergone a laparoscopic bilateral inguinal hernia repair as well as a laparoscopic umbilical hernia repair. In any case, she went to the operating room for a laparoscopic incisional hernia repair. This became infected and in 2017, she went back for laparotomy, drainage of an abscess and removal of the infected mesh. The patient convalesced quite well over the last 5 years and really did not have any problem until around Thanksgiving time when she developed some erythematous nodularity at the old right lower quadrant scar. This was drained in the office, but there was no significant purulence, no obvious foreign body. She subsequently underwent CT scan, which demonstrated an abscess cavity that tracked about 12 cm from the skin site all the way down to what appeared to be some potentially retained mesh. She comes to the OR today for exploration and removal.
OPERATIVE NOTE:
The patient was brought to the operating room suite and laid supine on the table, given general anesthetic. A Foley catheter was placed without incident. The abdomen was prepped with chlorhexidine and draped in the usual standard fashion. I made an elliptical incision around the lateral aspect of her appendectomy incision. This was then deepened down into the subcutaneous tissue, debriding any of the necrotic subcutaneous tissue and this was tracked all to be going below the fascia and we immediately identified a portion of the abscess cavity, which was subsequently drained out. I had already obtained cultures from her, had a previous incision and drainage in the office growing methicillin-sensitive Staph aureus and so no further cultures were really taken. At this point, we had a little bit more difficulty trying to get into the lower portion of the abscess cavity. We had not yet entered the abdomen at this point until it was a little difficult to know exactly where we are, but it was very clear that it was going to be difficult to do this through this roughly 6 cm transversely oriented incision and I thought rather than open up the entirety of the incision, I made a counter incision down to the lateral aspect of her C-section scar on the right side and I basically got into the same plane as the abscess cavity, which then allowed us to get further deeper into the abdominal wall. We could see the peritoneal layer. This was opened just below some very densely adherent small bowel to the upper portion of this dissection. At this point, we were able to see that more the right lower quadrant extending along the pelvic side wall was actually devoid of any adherent bowel or signs of infection and ultimately based on this, it became clear that this was a retroperitoneal or an extraperitoneal process at least more inferiorly. At this point, we spent some time lysing the adhesions of the small bowel to what was basically the intraperitoneal portion of the abscess cavity superiorly. This was done completely. There was probably just a 4 cm segment of the small bowel that was whose serosal surface was part of the abscess cavity. Once this was lysed, the whole right lower quadrant was really free. We inspected this loop of bowel. There was no full-thickness injury. It was hard to tell whether there is truly a serosal injury or whether there was just simply some of the abscess cavity on the serosa. This was trimmed away. It was inspected again. We imbricated some of the tissue over this area just in case there was truly a serosal tear in the area, but no full-thickness injury and no spillage of bile. A sponge was then placed to keep the bowel from getting into our way. The patient was also placed into Trendelenburg to assist with this. We had an instrument on the sponge for later retrieval. Once this portion of the abscess cavity had been actually opened up, we encountered a corner of the mesh and this part of the mesh was polypropylene, it was not at all incorporated into the tissue, just kind of free floating in this cavity and at first, this did not make a lot of sense since the thought was that she had intraperitoneal mesh that was infected and only partially removed at the time of her previous operation to remove infected mesh, but in reality that mesh was probably more fully removed. It just had seeded previously placed extraperitoneal laparoscopic inguinal mesh and only a portion of that mesh had been removed, probably leaving behind what looked to be incorporated at the time of that procedure, but ultimately it was contaminated leading to this outcome that this mesh that we found, we continued to follow this down using essentially blunt dissection with a peanut dissector, gently pulling on that mesh and trying to separate any of the surrounding tissue. We followed this down to 1 clear metallic fastener and that last little remnant of the mesh likely did pull-through the second fastener but we could tell by inspecting the mesh that the 3 sides were intact. It was just probably along the horizontal axis where you could see that the mesh had been essentially trimmed probably at the time of the previous procedure. This was handed off the field for gross evaluation. It was clearly polypropylene and it was clearly extraperitoneal. We inspected the abscess cavity. We palpated the region. There was significant induration. We did not see any other additional areas of mesh. At this point, the area was copiously irrigated. The peritoneal layer was closed to exclude the viscera after removing the previously placed 4 x 8 instruments. All sponge, needle and instrument counts were correct at this point. With the viscera excluded, we then laid in a #10 flat JP, which extended down to the bottom of this abscess cavity and then closed the fascia with a #1 PDS in a running fashion through the lower incision. The drain had been tunneled up. We were able to find the pinpoint communication between the lower connection and upper connection and that is where we guided the catheter through scar part. The drain was actually brought out through a separate stab incision even further laterally, sutured with a 2-0 nylon and then the fascial material was brought together with another #1 PDS through the upper incision. Any obvious necrotic chronically infected tissue was debrided. The purulence had all been removed as well as granulating tissue with copious irrigation and then finally ultimately the skin was closed loosely with skin clips. Dry dressings were applied. The Foley catheter was removed. Anesthesia service provided TAP block in this region. She was ultimately awoken from the anesthetic and returned to the PACU in stable condition having tolerated the procedure well.