Wiki New Coder needing help-Chamberlain procedure

KNLong

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Chesnee, SC
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Procedure:
1. Right anterior Chamberlain procedure with evacuation of pericardial effusion
2. Incision and drainage of lower sternal incision, skin and soft tissue
3. Removal of sternal wire x1

I am thinking it would be 39010 Rt, 20680 but I am not for sure. Any help or any resources would definitely be appreciative.

70-year-old male status post CABG x2 on January 1, 2021. He was readmitted with atrial fibrillation and rapid ventricular response. As a part of his work-up, he had a CT scan which identified a moderate pericardial effusion. Echo was performed which confirmed the effusion, but ruled out cardiac tamponade. He presents today for definitive management.

Intraoperative findings:
-VATS was attempted, but there was severe adhesions within the right pleural space. Small 2.5 cm right anterior incision, similar to Chamberlain procedure was performed at approximately the fifth intercostal space. Pericardium was identified and opened. 550 mL of bloody pericardial effusion was removed. There was no significant alteration in patient hemodynamics with drainage.
-Incision and drainage of lower sternum revealed necrotic appearing fat, but no purulent drainage. Culture swabs were taken. A single sternal wire was removed. There was dressed wet-to-dry.

Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table where he underwent general anesthesia with double-lumen endotracheal intubation. Monitoring lines and devices were placed by anesthesia. The patient was bumped to expose the right lateral chest wall. He was then prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.

A small 10 mm incision was made at the mid axillary line, roughly the sixth intercostal space. The soft tissues were divided with electrocautery. Access was attempted using an Optiview technique, but this was unsuccessful for entering into the pleural space. The intercostal muscle was divided with electrocautery for direct access, but it was evident that there was severe adhesions within the right pleural space.

Given this finding, decision was made to create a small 10 mm anterior incision at approximately the fifth intercostal space, right parasternal region. Intent was to gain access of the right pleural space using a different site in hopes that no further adhesions were identified. However, upon entering the right pleural space, it was evident that there was severe adhesions within the entirety of the pleural space. The 10 mm incision was extended medially to create a 2.5 cm working incision, similar to Chamberlain procedure. The pericardial and anterior mediastinal fat were divided with electrocautery. The pericardium was identified and carefully opened using electrocautery. A bloody effusion was then evacuated, with a total amount removed at 550 mL. A portion of this was collected within a trap and submitted for routine cultures.

After complete evacuation, small stab incision was made below the right costal margin. A 10 French round Jackson-Pratt was tunneled in the subcutaneous tissue and then positioned within the pericardial space under direct visualization. The soft tissues were then injected with half percent Marcaine for local anesthesia. The pectoralis muscle was reapproximated with 2-0 Vicryl. The soft tissues were reapproximated with 2-0 Vicryl. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound. The lateral 10 mm incision was closed in a similar fashion.

The lower sternal incision was then opened using a 15 blade scalpel. Total incision length was approximately 4 cm. Upon opening the incision, necrotic fat was identified. Culture swabs were taken and submitted for routine cultures. Wheat Lander was placed and the necrotic fat was removed and the area was debrided back to fresh bleeding subcutaneous tissue. An underlying sternal wire was removed x1. The area was then copiously irrigated with antibiotic solution containing tobramycin. It was then dressed wet-to-dry.
 
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