46040? 46270?
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Perirectal abscess.
POSTOPERATIVE DIAGNOSES:
Anal fistula and perirectal abscess.
PROCEDURE:
Excision of subcutaneous anal fistula and drainage of deep
perirectal abscess.
SURGEON:
ANESTHESIA:
Local and TIVA.
INDICATION:
This is a 73-year-old man who reported about a 2-week history
of perirectal pain. The pain gradually getting worse. He
went to the emergency room and noted to have perirectal
abscess. I discussed incision and drainage of the abscess
with the patient and his family including risk of bleeding,
infection, need for further operation, poor wound healing,
recurrence of the abscess, stool incontinence. He expressed
understanding and agreed to proceed with the procedure with
local and TIVA.
FINDINGS AT PROCEDURE:
The patient has anal fistula with the skin opening on the
right side at about the 2 o'clock position and *** fistula
is subcutaneous; it was removed and the patient has a very
large perirectal abscess; it was draining.
PROCEDURE NOTE:
The patient was placed on the lateral position with the right
side down. The buttocks were taped apart. Next, the perianal
area was infiltrated with 0.5% Marcaine with epinephrine and I
can see that patient has an opening on the skin and when I
probe that opening, it goes inside the rectum. Next, I used
electrocautery and removed the fistula. The fistula is above
the muscle. Deeper, I can see that the *** into an abscess
and copious amount of purulent drainage noted. Cultures
obtained and the cavity is about 8-9 cm in diameter, wound was
then packed and dry dressing applied. The patient was then
taken back to recovery room in stable condition. Blood loss
was minimal. All sponge and instrument counts were correct.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Perirectal abscess.
POSTOPERATIVE DIAGNOSES:
Anal fistula and perirectal abscess.
PROCEDURE:
Excision of subcutaneous anal fistula and drainage of deep
perirectal abscess.
SURGEON:
ANESTHESIA:
Local and TIVA.
INDICATION:
This is a 73-year-old man who reported about a 2-week history
of perirectal pain. The pain gradually getting worse. He
went to the emergency room and noted to have perirectal
abscess. I discussed incision and drainage of the abscess
with the patient and his family including risk of bleeding,
infection, need for further operation, poor wound healing,
recurrence of the abscess, stool incontinence. He expressed
understanding and agreed to proceed with the procedure with
local and TIVA.
FINDINGS AT PROCEDURE:
The patient has anal fistula with the skin opening on the
right side at about the 2 o'clock position and *** fistula
is subcutaneous; it was removed and the patient has a very
large perirectal abscess; it was draining.
PROCEDURE NOTE:
The patient was placed on the lateral position with the right
side down. The buttocks were taped apart. Next, the perianal
area was infiltrated with 0.5% Marcaine with epinephrine and I
can see that patient has an opening on the skin and when I
probe that opening, it goes inside the rectum. Next, I used
electrocautery and removed the fistula. The fistula is above
the muscle. Deeper, I can see that the *** into an abscess
and copious amount of purulent drainage noted. Cultures
obtained and the cavity is about 8-9 cm in diameter, wound was
then packed and dry dressing applied. The patient was then
taken back to recovery room in stable condition. Blood loss
was minimal. All sponge and instrument counts were correct.
