Help with CPT code:
The perineum was prepped and draped in the usual manner. A lone star retractor was placed and there was easy eversion of about 2 cm of mucosa, right and left side with less protrusion anterior and posterior. the right side was approached first. this was grasped with 2 allis clamps and rolapsed out as much as possible. Approximately a 2 cm edge of mucosa was excised from anterior to posterior using electrocautery and harmonic focus. once that was completed, the defect was closed with interrupted sutures. Similar procedure was performed on the left side. Examination at the end of the procedure revealed no protruding mucosa.
Findings: 2 cm rectal prolapse of mucosa.
The perineum was prepped and draped in the usual manner. A lone star retractor was placed and there was easy eversion of about 2 cm of mucosa, right and left side with less protrusion anterior and posterior. the right side was approached first. this was grasped with 2 allis clamps and rolapsed out as much as possible. Approximately a 2 cm edge of mucosa was excised from anterior to posterior using electrocautery and harmonic focus. once that was completed, the defect was closed with interrupted sutures. Similar procedure was performed on the left side. Examination at the end of the procedure revealed no protruding mucosa.
Findings: 2 cm rectal prolapse of mucosa.