AR2728
Expert
I've attached the operative report and I'm completely lost with what procedure code and modifiers to attach. The patient had an inguinal hernia repair perfomed at 13:03 -he was closed in recovery then complained of testicle pain and went back to OR at 17:09 due to concerns of ischemic testicle. Please help me with this one!
Preop Diag: status post left inguinal hernia repair, rule our ischemic testicle, Left testicle swelling and pain
Postop Diag: Intact left inguinal hernia repair w/no contstriction, torsion or abnormal blood flow, no evidence ischemia
Op Procedure:
Left Groin exploration with irriation and repeat closure
Intraoperative and postoperative doppler and uplex ultrasound exam of cord and testicle w/closure
The patient underwent rapid sequence general oral endotracheal anesthesia. Dressing was removed and he was subsequently prepped and draped in the usual sterile fashion. The testicles and perineum were prepped sterilely and with the testicle brought out in the operative wound. The patient was given preop antibiotics. The patient's previous incision was opened up and there was a small hematoma in the subcutaneous tissues due to a venous bleeder which was controlled with the dye. Hematoma was evacuated and the underlying scarpus fascia was opened up. Cord structures were noticed to be exiting from the reconstructed external ring where the external oblique aponeurosis had been closed. At this site the patient's cord structures appeared to be healthy. The external ring was checked and was not impinging on the cord structures The external oblique aponeurosis was opened up with sutures divided and the inguinal canal visualized. There was no hematoma. Repair was intact. Visualization of the internal ring revealed no constriction or obstruction of the cord structures at the reconstructed internal ring. A doppler device was brought up and there was good doppler signals along the entire cord. The patient had a small area of thrombosed vein along the cord structures noted at his initial exploration which was unchanged. There was adequate venous return. Doppler signals were obtained down to the pubic tubercle and were intact. The testicle was then pushed out of the operative area and was visualized. The patient had a very small hydrocele which was very minimal. The testicle was visualized and appeared to be healthy without any significant swelling or ischemia. Dop tones were not able to be heard over the testicle but they were all the way down to the epididymis along the entire cord structures. There was no evidence of torsion and the Gubernaculum was intact. Discussions were had with Dr. Urologist and an intraoperative testicular ultrasound was obtained sterilely. This revealed good flow along the entire cord. There was flow in the testicle on the left, although it was markedly decreased compared to the right. There was no evidence of torsion, obstruction or kinking anywhere along the length of the testicle itself or along the cord. Further discussions were had with Dr. Urologist and as Papaverine was not available Lidocaine without Epinephrine was sprinkled along the cord structures. In this fashion the testicle which appeared to be healthy was revisualized and there was increasing flow into the testicle. The testicle continued to be healthy. There was no abnormality noted. Flow in the left testicle was decreased compared to the right but was present. The testicle had no evidence of ischemia. The wound was irrigated with antibiotic solution. The testicle was carefully replaced into the scrotum to prevent any kinking. Dop tones continued to be intact as did intraoperative doppler ultrasound along the entire cord and into the testicle itself. The wound was irrigated with antibiotic solution and was then closed in layers. External oblique aponeurosis was closed laterally with running Vicryl suture but the external ring was left wide open medially to prevent any impingement on the cord. There had been no evidence of impingement on opening up the wound. The scarpus fascia was then reapproximated with another running Vicryl suture. The superficial subcutaneous tissues and deep dermis were reapproximated with interrupted Vicryl sutures and a running subcuticular Vicryl suture was used to reapproximate the skin edges. After closure of each layer the patient did have intraoperative doppler ultrasound confirming good flow in the testicle and along the cord. The wound was dressed with steri-strips and a sterile dressing and drapes were taken down. Scrotal ultrasound revealed normal testicles bilaterally. There was flow in both testicles, greater on the right than on the left but both appeared to be viable. Discussions had been had with Dr. Urologist who felt that this was adequate and that the testicle was healthy. He hypothesized that possibly some of the local injection with Epinephrine had caused some spasm, causing decreased flow to the testicle. The testicle was viable and does have flow currently. He felt that the patient would need no further workup unless he had further problems. The patient was subsequently awakened in the operating room and take to recovery in stable condition. Estimated blood loss was less than 5 cc's. Fluids included 1,500 of Crystalloid. There were no specimens to the lab. The patient tolerated the procedure well. There were no complications. Counts were correct at the end of the procedure X 2.
Preop Diag: status post left inguinal hernia repair, rule our ischemic testicle, Left testicle swelling and pain
Postop Diag: Intact left inguinal hernia repair w/no contstriction, torsion or abnormal blood flow, no evidence ischemia
Op Procedure:
Left Groin exploration with irriation and repeat closure
Intraoperative and postoperative doppler and uplex ultrasound exam of cord and testicle w/closure
The patient underwent rapid sequence general oral endotracheal anesthesia. Dressing was removed and he was subsequently prepped and draped in the usual sterile fashion. The testicles and perineum were prepped sterilely and with the testicle brought out in the operative wound. The patient was given preop antibiotics. The patient's previous incision was opened up and there was a small hematoma in the subcutaneous tissues due to a venous bleeder which was controlled with the dye. Hematoma was evacuated and the underlying scarpus fascia was opened up. Cord structures were noticed to be exiting from the reconstructed external ring where the external oblique aponeurosis had been closed. At this site the patient's cord structures appeared to be healthy. The external ring was checked and was not impinging on the cord structures The external oblique aponeurosis was opened up with sutures divided and the inguinal canal visualized. There was no hematoma. Repair was intact. Visualization of the internal ring revealed no constriction or obstruction of the cord structures at the reconstructed internal ring. A doppler device was brought up and there was good doppler signals along the entire cord. The patient had a small area of thrombosed vein along the cord structures noted at his initial exploration which was unchanged. There was adequate venous return. Doppler signals were obtained down to the pubic tubercle and were intact. The testicle was then pushed out of the operative area and was visualized. The patient had a very small hydrocele which was very minimal. The testicle was visualized and appeared to be healthy without any significant swelling or ischemia. Dop tones were not able to be heard over the testicle but they were all the way down to the epididymis along the entire cord structures. There was no evidence of torsion and the Gubernaculum was intact. Discussions were had with Dr. Urologist and an intraoperative testicular ultrasound was obtained sterilely. This revealed good flow along the entire cord. There was flow in the testicle on the left, although it was markedly decreased compared to the right. There was no evidence of torsion, obstruction or kinking anywhere along the length of the testicle itself or along the cord. Further discussions were had with Dr. Urologist and as Papaverine was not available Lidocaine without Epinephrine was sprinkled along the cord structures. In this fashion the testicle which appeared to be healthy was revisualized and there was increasing flow into the testicle. The testicle continued to be healthy. There was no abnormality noted. Flow in the left testicle was decreased compared to the right but was present. The testicle had no evidence of ischemia. The wound was irrigated with antibiotic solution. The testicle was carefully replaced into the scrotum to prevent any kinking. Dop tones continued to be intact as did intraoperative doppler ultrasound along the entire cord and into the testicle itself. The wound was irrigated with antibiotic solution and was then closed in layers. External oblique aponeurosis was closed laterally with running Vicryl suture but the external ring was left wide open medially to prevent any impingement on the cord. There had been no evidence of impingement on opening up the wound. The scarpus fascia was then reapproximated with another running Vicryl suture. The superficial subcutaneous tissues and deep dermis were reapproximated with interrupted Vicryl sutures and a running subcuticular Vicryl suture was used to reapproximate the skin edges. After closure of each layer the patient did have intraoperative doppler ultrasound confirming good flow in the testicle and along the cord. The wound was dressed with steri-strips and a sterile dressing and drapes were taken down. Scrotal ultrasound revealed normal testicles bilaterally. There was flow in both testicles, greater on the right than on the left but both appeared to be viable. Discussions had been had with Dr. Urologist who felt that this was adequate and that the testicle was healthy. He hypothesized that possibly some of the local injection with Epinephrine had caused some spasm, causing decreased flow to the testicle. The testicle was viable and does have flow currently. He felt that the patient would need no further workup unless he had further problems. The patient was subsequently awakened in the operating room and take to recovery in stable condition. Estimated blood loss was less than 5 cc's. Fluids included 1,500 of Crystalloid. There were no specimens to the lab. The patient tolerated the procedure well. There were no complications. Counts were correct at the end of the procedure X 2.
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