Help please

lindacoder

Guest
Messages
282
Location
Northeast Kansas AAPC
Best answers
0
PREOPERATIVE DIAGNOSIS: Low rectal tubulovillous adenoma with dysplasia.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE: Exam under anesthesia with transanal excision of polyps.

INDICATIONS FOR PROCEDURE: The patient is a 62-year-old female who was found to have a low rectal polyp. Biopsy showed a tubulovillous adenoma with some high-grade dysplasia. She now is to undergo transanal excision of this. It does not appear to be fixed to the underlying tissue.

DESCRIPTION OF PROCEDURE: In the lithotomy position, the anal area was prepped and draped in the usual fashion. This polyp was about 2 cm up from the anal verge. It was fairly friable. It was posterior at the 6 o'clock position.

I placed a 2-0 Vicryl proximal to this and then one on each quadrant inferiorly and on each lateral side. I then excised this mucosa staying above the sphincteric muscle. It was actually a little bit up above that and excised at normal-appearing deep tissue. It sort was very friable and wanted to tear, but we got around it completely. It was sent to pathology. Looking at it grossly I did not see signs of malignancy. I then reapproximated the edges longitudinally with that 2-0 Vicryl. An additional one was placed over this. At the completion this closed this very nicely. There were no signs of bleeding. Rigid sigmoidoscope showed there are no signs of narrowing and it looked good proximally as well as distally. After ensuring that this looked good, a pressure dressing was applied.

ESTIMATED BLOOD LOSS: Minimal.

Sponge and needle counts were correct. She tolerated the procedure and was taken to the recovery in satisfactory condition.


can't decide between 46606, 46611 or 46610
 
Top