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Need help coding this Operative Report:
NAME OF OPERATION
Ultrasound guided right flank hematoma drainage and pigtail catheter placement.
SURGEON
Scott J Brick DO
ANESTHESIA
INDICATIONS
This is a 37-year-old male who had repair of a large right flank hernia approximately three weeks ago. He developed a hematoma on initial postoperative visit, but wanted to manage this conservatively but then developed fevers, leukocytosis and was admitted to the Emergency Room. He had had a CT scan done, which showed some air pockets, which suggested possible infection, so the patient was seen for ultrasound guided drainage.
DESCRIPTION OF OPERATION
The patient was placed in the left lateral recumbant position in his ICU bed. Ultrasound guidance was there. The right flank was prepped and draped in the usual sterile fashion, injected with 1% lidocaine plain. Using an 8 French Huey catheter the hematoma was entered and aspirated immediately of 60 mL of old blood without any evidence of any purulent fluid. A 0.035 wire was placed through the Huey catheter, the Huey catheter was removed and then a 10-French pigtail catheter was placed within the pocket under ultrasound guidance. It was pigtailed in the cavity and hooked through a stopcock and Uroseal bag and placed on suction. It was sutured with a 3-0 silk and the provided adhesive dressing was then placed.
Need help coding this Operative Report:
NAME OF OPERATION
Ultrasound guided right flank hematoma drainage and pigtail catheter placement.
SURGEON
Scott J Brick DO
ANESTHESIA
INDICATIONS
This is a 37-year-old male who had repair of a large right flank hernia approximately three weeks ago. He developed a hematoma on initial postoperative visit, but wanted to manage this conservatively but then developed fevers, leukocytosis and was admitted to the Emergency Room. He had had a CT scan done, which showed some air pockets, which suggested possible infection, so the patient was seen for ultrasound guided drainage.
DESCRIPTION OF OPERATION
The patient was placed in the left lateral recumbant position in his ICU bed. Ultrasound guidance was there. The right flank was prepped and draped in the usual sterile fashion, injected with 1% lidocaine plain. Using an 8 French Huey catheter the hematoma was entered and aspirated immediately of 60 mL of old blood without any evidence of any purulent fluid. A 0.035 wire was placed through the Huey catheter, the Huey catheter was removed and then a 10-French pigtail catheter was placed within the pocket under ultrasound guidance. It was pigtailed in the cavity and hooked through a stopcock and Uroseal bag and placed on suction. It was sutured with a 3-0 silk and the provided adhesive dressing was then placed.