rejenia
Networker
Was unsure how to code this...
OPERATION:
1. Right groin exploration with redo right groin dissection, 22 modifier.
2. Resection of right femoral artery associated 4.5 cm lymphocele with
cystectomy of lymphocele cavity and open drainage of lymphocele with
cultures taken.
3. Ligation of associated lymphatic channels.
4. Scar revision with excision of lymphocutaneous fistula and complex groin
closure.
PROCEDURE IN DETAIL:
After appropriate informed consent was obtained, patient was brought to the
operating room and time-out performed. Patient was identified. Perioperative
antibiotics given. Right groin and leg prepped and draped in the usual
sterile manner. At the medial aspect of the incision a punctate sinus tract consistent with a lymphocutaneous fistula and this was draining clear
fluid. An incision was made over the prior groin incision in an oblique
fashion extending it medially for approximately 2 cm incapsulating the area of the pinpoint sinus tract. The skin and subcutaneous tissues were divided.
The groin was significantly scarred by the inflammatory process that had been going on with this lymphocele.
The inguinal ligament was ultimately identified and the pulsation of the common femoral artery just below this was felt.
Next 45 minutes to an hour were spent in meticulous dissection
of the 4.5 cm lymphocele with adherent desmoplastic reaction around
the common femoral artery laterally and inferiorly and the femoral vein
medially. Fairly dense adhesions to the femoral artery and femoral vein were noted.
This lead to prolongation of the operation and double the usual amount
of time and effort. A Harmonic scalpel was used to carefully dissect the
lymphocele cavity away from the femoral artery and femoral veins and in doing so, ligate the lymphatic channels contributing to the process. After
approximately an additional hour of circumferential dissection I was able to
mobilize the lymphocele cyst off the anterior surface of the femoral artery as
well as off the femoral vein.
There appeared to be an inferior supply of lymphatic channels going directly to this. These were suture ligated with 3-0
Prolene stick ties. Additional small lymphatic channels were cauterized with
the Harmonic scalpel. Once the lymphatic cavity was completely freed up the
cavity was opened under direct vision and straw colored fluid was noted.
Culture swabs were then taken. The cavity was adherent to the superior most aspect of the common femoral artery but there was no evidence of penetration or violation of the artery in any way.
A complete cystectomy of the lymphocele was then performed leaving only a small cuff of tissue on the femoral artery. The small cuff was then cauterized. The lymphatic capsule was sent to pathology. The groin was then checked once again for hemostasis which was present as well as any possible leaking lymphatic vessels.
I did not see any. After about 10 minutes I still had not seen any lymph leak in the area. Satisfied, I then irrigated the groin with multiple rounds of
antibiotic irrigation. A scar revision was then performed with excision of
the skin around the superior margin encompassing the sinus tract that I could see going to the skin.
At this point meticulous closure of the femoral sheath was done with interrupted Vicryl sutures. The deeper groin tissues were then
reapproximated with additional 3-0 interrupted Vicryl sutures, subdermal
sutures of Vicryl also used and the skin closed with staples. Sterile
dressings were then applied. Patient tolerated the procedure well and was
taken to the recovery room in satisfactory condition.
OPERATION:
1. Right groin exploration with redo right groin dissection, 22 modifier.
2. Resection of right femoral artery associated 4.5 cm lymphocele with
cystectomy of lymphocele cavity and open drainage of lymphocele with
cultures taken.
3. Ligation of associated lymphatic channels.
4. Scar revision with excision of lymphocutaneous fistula and complex groin
closure.
PROCEDURE IN DETAIL:
After appropriate informed consent was obtained, patient was brought to the
operating room and time-out performed. Patient was identified. Perioperative
antibiotics given. Right groin and leg prepped and draped in the usual
sterile manner. At the medial aspect of the incision a punctate sinus tract consistent with a lymphocutaneous fistula and this was draining clear
fluid. An incision was made over the prior groin incision in an oblique
fashion extending it medially for approximately 2 cm incapsulating the area of the pinpoint sinus tract. The skin and subcutaneous tissues were divided.
The groin was significantly scarred by the inflammatory process that had been going on with this lymphocele.
The inguinal ligament was ultimately identified and the pulsation of the common femoral artery just below this was felt.
Next 45 minutes to an hour were spent in meticulous dissection
of the 4.5 cm lymphocele with adherent desmoplastic reaction around
the common femoral artery laterally and inferiorly and the femoral vein
medially. Fairly dense adhesions to the femoral artery and femoral vein were noted.
This lead to prolongation of the operation and double the usual amount
of time and effort. A Harmonic scalpel was used to carefully dissect the
lymphocele cavity away from the femoral artery and femoral veins and in doing so, ligate the lymphatic channels contributing to the process. After
approximately an additional hour of circumferential dissection I was able to
mobilize the lymphocele cyst off the anterior surface of the femoral artery as
well as off the femoral vein.
There appeared to be an inferior supply of lymphatic channels going directly to this. These were suture ligated with 3-0
Prolene stick ties. Additional small lymphatic channels were cauterized with
the Harmonic scalpel. Once the lymphatic cavity was completely freed up the
cavity was opened under direct vision and straw colored fluid was noted.
Culture swabs were then taken. The cavity was adherent to the superior most aspect of the common femoral artery but there was no evidence of penetration or violation of the artery in any way.
A complete cystectomy of the lymphocele was then performed leaving only a small cuff of tissue on the femoral artery. The small cuff was then cauterized. The lymphatic capsule was sent to pathology. The groin was then checked once again for hemostasis which was present as well as any possible leaking lymphatic vessels.
I did not see any. After about 10 minutes I still had not seen any lymph leak in the area. Satisfied, I then irrigated the groin with multiple rounds of
antibiotic irrigation. A scar revision was then performed with excision of
the skin around the superior margin encompassing the sinus tract that I could see going to the skin.
At this point meticulous closure of the femoral sheath was done with interrupted Vicryl sutures. The deeper groin tissues were then
reapproximated with additional 3-0 interrupted Vicryl sutures, subdermal
sutures of Vicryl also used and the skin closed with staples. Sterile
dressings were then applied. Patient tolerated the procedure well and was
taken to the recovery room in satisfactory condition.