nabernhardt
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not sure whether to go with 44950 or 44960? says ruptured but not abscess.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis with marked inflammatory enlargement
of the appendix. Localized rupture.
FINDINGS: The appendix was approximately 3 or more centimeters in diameter. It was
markedly inflamed. There was a phlegmon of small bowel around the appendix. There was really no true abscess. The cecum where the appendix attached was also markedly enlarged and thickened.
PROCEDURE: The base of the appendix, cecum and mesentery could really not be distinguished well. There was a slight amount of purulent material just outside the appendix but no significant abscess size. After repeated attempts and changes in position to aid in visualization, the abdomen was subsequently entered through a vertical midline lower abdominal incision, removing the previous ports and incorporating them into the incision. Through this, the right colon was mobilized laterally and brought into the operative field. The markedly inflammatory process was confirmed
clinically. The small bowel was further dissected free from the area. After identifying the
mesoappendix and dividing this further with the harmonic scalpel, which had been started initially with the laparoscopic approach, this was completed until the appendix and inflammatory mass was freed to the cecum. The cecum was very thickened at the insertion site of the appendix and I could not really distinguish a good clean site for suture or staple there to vision. Above the inflammatory process in the cecum and below the ileocecal valve, a site was selected. The TA-90 stapling device was placed across this portion and after assuring adequate positioning and confirmation once again of the patent ileocecal valve, the stapler was fired and then the cecum and appendix was removed
en bloc. The abdominal cavity was irrigated with multiple liters of irrigant and after assuring adequate hemostasis in the mesoappendix, a drain was placed in this location and brought out through a separate stab wound in the right side of the abdomen. This was sutured in place at the level of the skin with Prolene suture. After completing the irrigation of the abdominal cavity and confirming that the small bowel from the ligament of Treitz to the ileocecal valve was free from the adhesive process and confirmation of adequate placement of a nasogastric tube by palpation, the fascia was closed with a running number 1 Prolene suture on the midline fascia, incorporating a small portion of peritoneum to aid in closure. The subcutaneous tissue was then irrigated and the skin was closed with skin clips, incorporating the previous trocar incisions, which were at the
superior and inferior portion of this in a crosshatch position.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis with marked inflammatory enlargement
of the appendix. Localized rupture.
FINDINGS: The appendix was approximately 3 or more centimeters in diameter. It was
markedly inflamed. There was a phlegmon of small bowel around the appendix. There was really no true abscess. The cecum where the appendix attached was also markedly enlarged and thickened.
PROCEDURE: The base of the appendix, cecum and mesentery could really not be distinguished well. There was a slight amount of purulent material just outside the appendix but no significant abscess size. After repeated attempts and changes in position to aid in visualization, the abdomen was subsequently entered through a vertical midline lower abdominal incision, removing the previous ports and incorporating them into the incision. Through this, the right colon was mobilized laterally and brought into the operative field. The markedly inflammatory process was confirmed
clinically. The small bowel was further dissected free from the area. After identifying the
mesoappendix and dividing this further with the harmonic scalpel, which had been started initially with the laparoscopic approach, this was completed until the appendix and inflammatory mass was freed to the cecum. The cecum was very thickened at the insertion site of the appendix and I could not really distinguish a good clean site for suture or staple there to vision. Above the inflammatory process in the cecum and below the ileocecal valve, a site was selected. The TA-90 stapling device was placed across this portion and after assuring adequate positioning and confirmation once again of the patent ileocecal valve, the stapler was fired and then the cecum and appendix was removed
en bloc. The abdominal cavity was irrigated with multiple liters of irrigant and after assuring adequate hemostasis in the mesoappendix, a drain was placed in this location and brought out through a separate stab wound in the right side of the abdomen. This was sutured in place at the level of the skin with Prolene suture. After completing the irrigation of the abdominal cavity and confirming that the small bowel from the ligament of Treitz to the ileocecal valve was free from the adhesive process and confirmation of adequate placement of a nasogastric tube by palpation, the fascia was closed with a running number 1 Prolene suture on the midline fascia, incorporating a small portion of peritoneum to aid in closure. The subcutaneous tissue was then irrigated and the skin was closed with skin clips, incorporating the previous trocar incisions, which were at the
superior and inferior portion of this in a crosshatch position.
