jmassari
Contributor
Hi. Having a hard time figuring this one out! Reason to take the patient to the OR was to replace the mushroom catheter/drain which ended up taking substantial time. Below is the op note. Any help in coding this drain exchange and/or sinus debridement is appreciated. Thanks!
Indications: Chronic presacral sinus secondary to anastomotic leak.
Description of Procedure: The patient was brought to the abdomen placed on the operative table in supine position. After administration of adequate anesthesia the patient was placed in lithotomy position. The patient was prepped and draped in usual sterile fashion. Timeout was performed. The patient received preoperative antibiotics in the form of Flagyl. The perianal area was injected with 30 mL of 1% lidocaine with epinephrine and 0.5% Marcaine mixed. Digital rectal examination revealed the drain was in a posterior presacral cavity. Perianal examination revealed no masses. No fistula or fissure. Digital rectal examination did not reveal any clear mass. The rectum proximal to the area of the posterior sinus was collapsed and scarred down. The drain was then removed in its entirety. The area of the posterior sinus was then probed. Passage of the new catheter which was a 12 French mushroom catheter was very difficult. Because of the angulation and granulation tissue present was difficult to advance the catheter. Approximately 1 hour was spent attempting to do this. Finally the area of the sinus was debrided bluntly and sharply. Granulation tissue was evacuated. A flexible sigmoidoscopy was performed up to the level of the collapsed rectum. There was no signs of mass. Biopsies were taken. Colonoscope was removed. The 12 French mushroom drain was then placed within the cavity. It appeared to stay in place. It was then secured to the left buttock with a 0 silk stitch. The perianal area was then cleaned dried and dressings applied. The patient was then awakened from anesthesia in stable condition.
Indications: Chronic presacral sinus secondary to anastomotic leak.
Description of Procedure: The patient was brought to the abdomen placed on the operative table in supine position. After administration of adequate anesthesia the patient was placed in lithotomy position. The patient was prepped and draped in usual sterile fashion. Timeout was performed. The patient received preoperative antibiotics in the form of Flagyl. The perianal area was injected with 30 mL of 1% lidocaine with epinephrine and 0.5% Marcaine mixed. Digital rectal examination revealed the drain was in a posterior presacral cavity. Perianal examination revealed no masses. No fistula or fissure. Digital rectal examination did not reveal any clear mass. The rectum proximal to the area of the posterior sinus was collapsed and scarred down. The drain was then removed in its entirety. The area of the posterior sinus was then probed. Passage of the new catheter which was a 12 French mushroom catheter was very difficult. Because of the angulation and granulation tissue present was difficult to advance the catheter. Approximately 1 hour was spent attempting to do this. Finally the area of the sinus was debrided bluntly and sharply. Granulation tissue was evacuated. A flexible sigmoidoscopy was performed up to the level of the collapsed rectum. There was no signs of mass. Biopsies were taken. Colonoscope was removed. The 12 French mushroom drain was then placed within the cavity. It appeared to stay in place. It was then secured to the left buttock with a 0 silk stitch. The perianal area was then cleaned dried and dressings applied. The patient was then awakened from anesthesia in stable condition.