NPSDEB
Networker
Hello-
Any input is greatly appreciated. Patient was coming in for free flap reconstruction and removal of tissue expanders post mastectomy. The free flap was discontinued due to extensive clotting and necrosis of flap. Also there was a co-surgeon involved. We have been trying to figure out what to bill for this.
PREOPERATIVE DIAGNOSIS: breast ca, bilateral absence breast and nipple
POSTOPERATIVE DIAGNOSIS: same, +non viable free flap
PROCEDURES:
Attempted free flap reconstructon (SIEA) of bilateral breast after SIEA delay
Debriedment non viable free flaps
Abdominal closure, repair of rectus diastasis
Closure breast with pectoralis repair bilateral
ANESTHESIA: GETA
FINDINGS:
Flaps initially pink, with 2second capillary refil on exam, SIEA vessels with palpable and auditory signals on doppler. However examination of bilateral flaps demonstrates extensive clotting and necrosis on underside of flap with peripheral loss, capillary refill limited to superficial layers.
There was size miss match between chest and SIEA vessels however flow through the attempted anastamosis on left was established. No flow into flap obtained, there was significant micro clot in flap which appeared to prevent flow thorugh.
EBL: 100cc
DESCRIPTION OF PROCEDURE:
The patient had been previously consented and had an opportunity to ask questions, they were in agreement with proceeding. The site was marked. The patient was brought the procedure room and placed in the supine position they were appropriately padded. General anesthesia was induced. Preoperative antibiotics were addressed as was warming and SCDs. The patient was prepped and draped in usual sterile fashion. A team pause was held, an concerns were addressed.
Abdomen flaps are examined, these are superficially pink with capillary refill at periphy some necrotic tissue noted and debrided, as well as more significant debriedment at underside of flaps.
The SIEA vessles have palpable and auditory signal.
The left chest vessels are prepared with notable size missmatch as the left vessels at chest are friable but larger than the left abdominal vessels which appear to have significant spasm not relieved by warming, rest or 4%lidocaine. After debridement of left flap it is successfully conneted to the IMA with flow through artery which is followed by strip test and doppler into flap, however no venous return, no signal established in flap. The arteries are clamped and the venous system flushed with heparin with finding of significant clott which prevents flow through. The anastamosis is taken down and interrogated with adequate inflow from IMA and no flaw in anastamosis, no clot or narrowing. Given volume of microclot and inability to flush through flap it is considered futile by entire team at this point. The flaps are further interrogated as they are debrided and noted to be necrotic throughout with microclott disseminated throughout. At the chest the JPs had been removed prior to starting case and are replaced with 15F and secured. The left IMA and veins are clipped, the pectoralis is repaired over the removed bone with 3-0 vicryl. The dermis and skin are closed with combination of 3-0 vicryl then 3-0 prolene pending next stage. On the right the vessels had been prepared but not cut. The pectoralis is repaired and laid down as TE was subpectoral on this side. The dermis and skin are closed in similar fashion. ON the abdomen a subcutanous tunnel is dissected to allow recuts diastasis repair. This is accomplished with #2 quill in two layers each above and below the umbilicus. The abodmen is then irrigated and checked for hemostasis. A right and left JP are placed and secured laterally. The patient is placed in beach chair position. 2-0 vicryl interrupted are used to secure scarpas then a running 2-0 quill is used at scarpas. This is followed by 4-0 strattafix in two layers to dermis and subcutaneous. The umbilicus is then repaired with 4-0 vicry interrupted then 4-0 rapid at the skin. The incisoins are dressed with bacitracin, xeroform as are drains then abds. A binder and bra are placed.
All counts were correct at the termination of the case. The patient was extubated and taken to pacu in stable condition.
COMPLICATIONS: Flaps non viable
Any input is greatly appreciated. Patient was coming in for free flap reconstruction and removal of tissue expanders post mastectomy. The free flap was discontinued due to extensive clotting and necrosis of flap. Also there was a co-surgeon involved. We have been trying to figure out what to bill for this.
PREOPERATIVE DIAGNOSIS: breast ca, bilateral absence breast and nipple
POSTOPERATIVE DIAGNOSIS: same, +non viable free flap
PROCEDURES:
Attempted free flap reconstructon (SIEA) of bilateral breast after SIEA delay
Debriedment non viable free flaps
Abdominal closure, repair of rectus diastasis
Closure breast with pectoralis repair bilateral
ANESTHESIA: GETA
FINDINGS:
Flaps initially pink, with 2second capillary refil on exam, SIEA vessels with palpable and auditory signals on doppler. However examination of bilateral flaps demonstrates extensive clotting and necrosis on underside of flap with peripheral loss, capillary refill limited to superficial layers.
There was size miss match between chest and SIEA vessels however flow through the attempted anastamosis on left was established. No flow into flap obtained, there was significant micro clot in flap which appeared to prevent flow thorugh.
EBL: 100cc
DESCRIPTION OF PROCEDURE:
The patient had been previously consented and had an opportunity to ask questions, they were in agreement with proceeding. The site was marked. The patient was brought the procedure room and placed in the supine position they were appropriately padded. General anesthesia was induced. Preoperative antibiotics were addressed as was warming and SCDs. The patient was prepped and draped in usual sterile fashion. A team pause was held, an concerns were addressed.
Abdomen flaps are examined, these are superficially pink with capillary refill at periphy some necrotic tissue noted and debrided, as well as more significant debriedment at underside of flaps.
The SIEA vessles have palpable and auditory signal.
The left chest vessels are prepared with notable size missmatch as the left vessels at chest are friable but larger than the left abdominal vessels which appear to have significant spasm not relieved by warming, rest or 4%lidocaine. After debridement of left flap it is successfully conneted to the IMA with flow through artery which is followed by strip test and doppler into flap, however no venous return, no signal established in flap. The arteries are clamped and the venous system flushed with heparin with finding of significant clott which prevents flow through. The anastamosis is taken down and interrogated with adequate inflow from IMA and no flaw in anastamosis, no clot or narrowing. Given volume of microclot and inability to flush through flap it is considered futile by entire team at this point. The flaps are further interrogated as they are debrided and noted to be necrotic throughout with microclott disseminated throughout. At the chest the JPs had been removed prior to starting case and are replaced with 15F and secured. The left IMA and veins are clipped, the pectoralis is repaired over the removed bone with 3-0 vicryl. The dermis and skin are closed with combination of 3-0 vicryl then 3-0 prolene pending next stage. On the right the vessels had been prepared but not cut. The pectoralis is repaired and laid down as TE was subpectoral on this side. The dermis and skin are closed in similar fashion. ON the abdomen a subcutanous tunnel is dissected to allow recuts diastasis repair. This is accomplished with #2 quill in two layers each above and below the umbilicus. The abodmen is then irrigated and checked for hemostasis. A right and left JP are placed and secured laterally. The patient is placed in beach chair position. 2-0 vicryl interrupted are used to secure scarpas then a running 2-0 quill is used at scarpas. This is followed by 4-0 strattafix in two layers to dermis and subcutaneous. The umbilicus is then repaired with 4-0 vicry interrupted then 4-0 rapid at the skin. The incisoins are dressed with bacitracin, xeroform as are drains then abds. A binder and bra are placed.
All counts were correct at the termination of the case. The patient was extubated and taken to pacu in stable condition.
COMPLICATIONS: Flaps non viable