lindacoder
Guest
not sure what to use for the groin exploration. I can use 38790 for mapping of the lymphocele.
PREOPERATIVE DIAGNOSIS: Right groin lymphocele status post right fem distal bypass with vein graft
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Right groin wound exploration with isosulfan blue administration for lymphatic mapping, ligation of lymphatic vessels, Tisseel application and Praveena wound VAC placement.
ANESTHESIA: General.
SPECIMENS:
1. Right groin fluid on a culture swab to microbiology. 2. Right groin hematoma to microbiology.
ESTIMATED BLOOD LOSS: Minimal.
FINDINGS:
1. A small hematoma to the right groin site.
2. Isosulfan blue administration with identification of small lymphatic vessels with mild extravasation of blue dye into the right groin site. 3. Excellent pulsatility of the vein bypass graft.
INDICATIONS FOR PROCEDURE: The patient is a 53-year-old gentleman who underwent a right fem to anterior tibial bypass vein graft. He had had a prior groin exposure for right femoral to infrageniculate popliteal artery bypass in the past. He had extensive scarring to the right groin site. Postoperatively, he developed a lymphocele and then subsequent lymphocutaneous fistula. Given this fact, intervention was indicated. The risks, benefits, and alternatives of procedure were discussed with the patient, informed consent was obtained.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room theater. He was placed in supine position. General anesthesia was induced. Preoperative antibiotics were administered. The patient's right groin and leg were then prepped and draped in normal sterile fashion.
4 mL of isosulfan blue dye were injected subdermally to the right thigh. This was then massaged and 5 minutes allow for this to traverse the lymphatic vessels. The staples were then removed from the right groin site. The Vicryl sutures were removed as well. There was a moderate lymphocele cavity identified without a fibrous capsule as this was in the early postoperative period. Once the wound was opened, evaluation for blue dye was sought. He did have at the inferior aspect of the wound, evidence of blue dye to the lymphatics with only mild extravasation at this point. These lymphatic branches were identified and controlled with Hemoclips. There was a large lymphatic vessel lateral to the wound and this was ligated with a Hemoclip as well. The wound was then monitored and there was found to be no further extravasation of fluid or blue dye. There was a small hematoma within the wound site. This was sent for microbiology. The fluid was cultured with a culture swab and was sent as well. There was excellent pulsatility in the vein graft.
The groin was then closed in 3 separate layers with a #1 Vicryl suture. Tisseel with 2 separate vials was then applied between each layer of the closure. The edges of the skin were then excised to freshen the skin margins as the lateral aspect was macerated from the fluid drainage. The skin was then closed loosely with staples. The Pravena wound VAC was then applied over the staple line and held an excellent seal.
The patient tolerated the procedure well. There were no complications. All counts were correct as reported to me at the end of the case.
Any thoughts???
Thanks
PREOPERATIVE DIAGNOSIS: Right groin lymphocele status post right fem distal bypass with vein graft
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Right groin wound exploration with isosulfan blue administration for lymphatic mapping, ligation of lymphatic vessels, Tisseel application and Praveena wound VAC placement.
ANESTHESIA: General.
SPECIMENS:
1. Right groin fluid on a culture swab to microbiology. 2. Right groin hematoma to microbiology.
ESTIMATED BLOOD LOSS: Minimal.
FINDINGS:
1. A small hematoma to the right groin site.
2. Isosulfan blue administration with identification of small lymphatic vessels with mild extravasation of blue dye into the right groin site. 3. Excellent pulsatility of the vein bypass graft.
INDICATIONS FOR PROCEDURE: The patient is a 53-year-old gentleman who underwent a right fem to anterior tibial bypass vein graft. He had had a prior groin exposure for right femoral to infrageniculate popliteal artery bypass in the past. He had extensive scarring to the right groin site. Postoperatively, he developed a lymphocele and then subsequent lymphocutaneous fistula. Given this fact, intervention was indicated. The risks, benefits, and alternatives of procedure were discussed with the patient, informed consent was obtained.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room theater. He was placed in supine position. General anesthesia was induced. Preoperative antibiotics were administered. The patient's right groin and leg were then prepped and draped in normal sterile fashion.
4 mL of isosulfan blue dye were injected subdermally to the right thigh. This was then massaged and 5 minutes allow for this to traverse the lymphatic vessels. The staples were then removed from the right groin site. The Vicryl sutures were removed as well. There was a moderate lymphocele cavity identified without a fibrous capsule as this was in the early postoperative period. Once the wound was opened, evaluation for blue dye was sought. He did have at the inferior aspect of the wound, evidence of blue dye to the lymphatics with only mild extravasation at this point. These lymphatic branches were identified and controlled with Hemoclips. There was a large lymphatic vessel lateral to the wound and this was ligated with a Hemoclip as well. The wound was then monitored and there was found to be no further extravasation of fluid or blue dye. There was a small hematoma within the wound site. This was sent for microbiology. The fluid was cultured with a culture swab and was sent as well. There was excellent pulsatility in the vein graft.
The groin was then closed in 3 separate layers with a #1 Vicryl suture. Tisseel with 2 separate vials was then applied between each layer of the closure. The edges of the skin were then excised to freshen the skin margins as the lateral aspect was macerated from the fluid drainage. The skin was then closed loosely with staples. The Pravena wound VAC was then applied over the staple line and held an excellent seal.
The patient tolerated the procedure well. There were no complications. All counts were correct as reported to me at the end of the case.
Any thoughts???
Thanks