AR2728
Expert
Open Chole intended-not completed note states "opened incision hernia defects"
I've attached the scrubbed note on this one. I believe I'm only going to bill for the incisional hernia repair 49565--but really not positive. Assistance will be much appreciated!!
PREOPERATIVE DIAGNOSIS: Symptomatic cholelithiasis with history of calculus
cholecystitis and previous cholecystostomy with extraction
of stones.
POSTOPERATIVE DIAGNOSIS: Same with findings of abundant right upper quadrant
adhesions and inability to safely reach gallbladder.
PROCEDURE PERFORMED: Right upper quadrant exploration with adhesiolysis and
repair of right upper quadrant incisional herniations.
Right upper quadrant incision was made in line with the old incision and this was carried down to subcutaneous tissue with #15 Bard-Parker blade and this was carried down to the level of the fascia where multiple incisional hernias were noted. The incision was opened along with the hernias and dissection proceeded down to the right upper quadrant. Patient was found to have abundant adhesions of omentum to the anterior abdominal wall and
multiple attempts at adhesiolysis were done with attempts to identify the gallbladder but
gallbladder could never be safely identified because of the abundant amount of adhesions located in the right upper quadrant. After multiple attempts were made recognizing that there was a risk of causing injury to structures, decision was made to terminate any further attempt at reaching the gallbladder and therefore decision was then made to proceed with closure. After this decision was made, all hernias were identified and defects were opened and then the incision was closed with a running #1 Maxon suture started from either end of the incision and tied in the middle of the incision and this was successfully approximated in the fascial edges and repairing all of the hernia defects.
I've attached the scrubbed note on this one. I believe I'm only going to bill for the incisional hernia repair 49565--but really not positive. Assistance will be much appreciated!!
PREOPERATIVE DIAGNOSIS: Symptomatic cholelithiasis with history of calculus
cholecystitis and previous cholecystostomy with extraction
of stones.
POSTOPERATIVE DIAGNOSIS: Same with findings of abundant right upper quadrant
adhesions and inability to safely reach gallbladder.
PROCEDURE PERFORMED: Right upper quadrant exploration with adhesiolysis and
repair of right upper quadrant incisional herniations.
Right upper quadrant incision was made in line with the old incision and this was carried down to subcutaneous tissue with #15 Bard-Parker blade and this was carried down to the level of the fascia where multiple incisional hernias were noted. The incision was opened along with the hernias and dissection proceeded down to the right upper quadrant. Patient was found to have abundant adhesions of omentum to the anterior abdominal wall and
multiple attempts at adhesiolysis were done with attempts to identify the gallbladder but
gallbladder could never be safely identified because of the abundant amount of adhesions located in the right upper quadrant. After multiple attempts were made recognizing that there was a risk of causing injury to structures, decision was made to terminate any further attempt at reaching the gallbladder and therefore decision was then made to proceed with closure. After this decision was made, all hernias were identified and defects were opened and then the incision was closed with a running #1 Maxon suture started from either end of the incision and tied in the middle of the incision and this was successfully approximated in the fascial edges and repairing all of the hernia defects.