dlashua
Networker
Hello - below is an OP note I received. I would appreciate feedback and opinions on how this should be coded:
Preoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva
Postoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva
Anesthesia: Spinal
Description of Procedure:
An approximate 3 cm wide by 2.5 cm AP diameter of the condylomatous lesions in the posterior fourchette, extending from the right to the left and extending about a 1.5 cm to 2 cm from the midline on both sides. This area is extended to the hymenal ring and also within about 4 mm of the anus. This entire area was incised after the area was drawn with a marking pen.
The underlying tissue, especially in the midline, was quite scarred secondary to episiotomies done in the past. There was no sphincter tissue noted in this area, which was significantly scarred. A sliver of tissue, approximately 1 cm long and about 5 mm wide, at 12 o'clock, right at the entrance of the vagina was taken, to allow undermining of the vaginal mucosa, so that the area could be closed without tension. The vagina was undermined for several centimeters up into the vaginal area, this was normal appearing mucosa.
Gloves were changed and a rectal exam was done, which revealed no defect in the mucosa of the rectum, and no good sphincter tone in the rectal sphincter area. The scarred ends of the sphincter were dissected out, as if doing a 3rd degree repair and the scarred sphincter was then approximated at 12 o'clock with 2 sutures of 0-Vicryl. The mucosa was then approximated without any tension from the most caudal area, up towards the hymenal ring. At this point, this suture of 3-0 Vicryl was tied, and then the vaginal mucosa was brought down over this area, and extended out towards the perineum, to hopefully allow improved healing and less dyspareunia. The mucosa was sutured to the cut edges of the vulvar skin, and hemostasis was excellent at this point.
The patient tolerated the procedure well and was sent to the recovery room in good condition.
Thank you,
Doss
Preoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva
Postoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva
Anesthesia: Spinal
Description of Procedure:
An approximate 3 cm wide by 2.5 cm AP diameter of the condylomatous lesions in the posterior fourchette, extending from the right to the left and extending about a 1.5 cm to 2 cm from the midline on both sides. This area is extended to the hymenal ring and also within about 4 mm of the anus. This entire area was incised after the area was drawn with a marking pen.
The underlying tissue, especially in the midline, was quite scarred secondary to episiotomies done in the past. There was no sphincter tissue noted in this area, which was significantly scarred. A sliver of tissue, approximately 1 cm long and about 5 mm wide, at 12 o'clock, right at the entrance of the vagina was taken, to allow undermining of the vaginal mucosa, so that the area could be closed without tension. The vagina was undermined for several centimeters up into the vaginal area, this was normal appearing mucosa.
Gloves were changed and a rectal exam was done, which revealed no defect in the mucosa of the rectum, and no good sphincter tone in the rectal sphincter area. The scarred ends of the sphincter were dissected out, as if doing a 3rd degree repair and the scarred sphincter was then approximated at 12 o'clock with 2 sutures of 0-Vicryl. The mucosa was then approximated without any tension from the most caudal area, up towards the hymenal ring. At this point, this suture of 3-0 Vicryl was tied, and then the vaginal mucosa was brought down over this area, and extended out towards the perineum, to hopefully allow improved healing and less dyspareunia. The mucosa was sutured to the cut edges of the vulvar skin, and hemostasis was excellent at this point.
The patient tolerated the procedure well and was sent to the recovery room in good condition.
Thank you,
Doss
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