Wiki Need help with Cpt craniotomy wound for dehiscence

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SURGERY/PROCEDURE(S):
Expression of right temporal craniotomy wound for dehiscence debridement washout cultures and closure

ANESTHESIA: General

SURGERY/PROCEDURE DETAILS: This patient had recurrent wound dehiscence he is status post craniotomy for glioblastoma multiform a x2 and status post radiation who was right temporal incision did not heal very well and it repeatedly dehisced and finally it required to be operated on in the operating room. The procedure was explained to the patient and his wife and they gave me verbal and written consent. After the huddle in the presurgical area patient was brought to the operating room and general endotracheal anesthesia was induced. Audible surgical timeout was taken we held off on giving antibiotics until we culture the site of the surgery. In the supine position with a blanket roll underneath the right shoulder but the head was turned to the and the right temporal incision sutures were removed. As soon as the sutures were removed a seroma started oozing out which I collected in a test tube and sent it for gram stain cultures aerobic anaerobic. I opened the incision and remove the underlying sutures inspected the site of the craniotomy. There was no purulent material. I removed the small bone flap by getting the screws out from the bur hole cover. The underlying epidural tissue consisted of the DuraSeal and DuraGen which I removed. There was a defect in the dura inferiorly through which I could see CSF puddling. I went through the track of the craniotomy and I swabbed the tumor resection area and sent it for gram stain and cultures but at no time did I see any purulent material coming out to suggest a gross infection. I exposed the dura along the edges of the craniectomy where the dural defect was and I debrided the necrotic brain on the surface placed a piece of Surgicel followed by a Gelfoam and then I used Tisseal solution followed by another piece of Surgicel. I grafted the dura with a piece of temporalis fascia closing it with 4-0 Nurolon suture. On top of this construct I placed a piece of DuraGen followed by DuraSeal bone flap was replaced and secured with the screws and the Stryker bur hole cover. Temporalis muscle and fascia was approximated with interrupted 3-0 Vicryl sutures. Subcutaneous tissue was closed with interrupted 3-0 Vicryl sutures. The lower part of the incision was closed in a vertical mattress with interrupted sutures the upper portion was closed with continuous locked nylon suture. Sterile dressing was then applied at the end of the operation the needle count instrument count and sponge count was correct my estimated blood loss was 15 cc patient was extubated and sent to the recovery room in stable condition.

PRE-OP/PRE-PROCEDURE DIAGNOSIS: Craniotomy wound dehiscence
 
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