GSCoder07
Networker
This, for me, is a head scratcher. How would you code this? I don't know if I'm missing something or this is poor documentation. Any help would be greatly appreciated!! Thanks!!!
PREOPERATIVE DIAGNOSES: Wound dehiscence with chronic wound infection,
postoperative.
POSTOPERATIVE DIAGNOSES:
1. Wound dehiscence with chronic wound infection, postoperative.
2. Large ventral incisional hernia.
OPERATION:
1. Repair large ventral incisional hernia.
2. Debridement of wound.
3. Component separation.
4. Placement of retention sutures.
We took down some adhesions from the greater omentum to the fascial edges and freed
up this greater omentum and small bowel. There was another defect near the
umbilicus. We extended the incision superiorly and opened up into this umbilical
portion of the hernia, and this made this all just one large hernia. The midline
fascia really would not come together well, and so I went ahead with a lateral
release and a component separation. We had developed flaps laterally and then I
divided the fascia of the external oblique lateral to the rectus muscle, and this
brought the fascia in I would say about 3 or 4 cm on each side and then we were able
to really reapproximate the midline fascia without tension. We then irrigated this
area copiously with vancomycin-containing irrigation solution and the pulse
irrigator. There was no free purulence anywhere. We debrided some of this
hypertrophic fibrinous tissue from the fascial edges. We then placed retention
sutures using #2 nylon sutures and I placed them underneath the fascia but
extraperitoneal; I placed three of these, this was from about the umbilicus down to
just around the suprapubic area. I really could not feel or see the bladder at all.
We then went ahead and closed the midline fascia using a running double-strength #1
PDS and a nice, really tension-free approximation was obtained. We then re-irrigated
this area and obtained good hemostasis using electrocautery.
I then placed Jackson-Pratt drains under the flaps that we raised and brought them
out inferior stab incisions on each side; these were 19-French round Jackson-Pratt's.
I then closed the subcutaneous tissue using a running 2-0 Vicryl and we put another
drain just above the fascia and underneath the subcutaneous tissue and brought it out
a superior left upper quadrant stab incision. We then closed the skin with staples
and I tightened the retention sutures over plastic bridges and tightened these down
appropriately. The patient tolerated this procedure well.
PREOPERATIVE DIAGNOSES: Wound dehiscence with chronic wound infection,
postoperative.
POSTOPERATIVE DIAGNOSES:
1. Wound dehiscence with chronic wound infection, postoperative.
2. Large ventral incisional hernia.
OPERATION:
1. Repair large ventral incisional hernia.
2. Debridement of wound.
3. Component separation.
4. Placement of retention sutures.
We took down some adhesions from the greater omentum to the fascial edges and freed
up this greater omentum and small bowel. There was another defect near the
umbilicus. We extended the incision superiorly and opened up into this umbilical
portion of the hernia, and this made this all just one large hernia. The midline
fascia really would not come together well, and so I went ahead with a lateral
release and a component separation. We had developed flaps laterally and then I
divided the fascia of the external oblique lateral to the rectus muscle, and this
brought the fascia in I would say about 3 or 4 cm on each side and then we were able
to really reapproximate the midline fascia without tension. We then irrigated this
area copiously with vancomycin-containing irrigation solution and the pulse
irrigator. There was no free purulence anywhere. We debrided some of this
hypertrophic fibrinous tissue from the fascial edges. We then placed retention
sutures using #2 nylon sutures and I placed them underneath the fascia but
extraperitoneal; I placed three of these, this was from about the umbilicus down to
just around the suprapubic area. I really could not feel or see the bladder at all.
We then went ahead and closed the midline fascia using a running double-strength #1
PDS and a nice, really tension-free approximation was obtained. We then re-irrigated
this area and obtained good hemostasis using electrocautery.
I then placed Jackson-Pratt drains under the flaps that we raised and brought them
out inferior stab incisions on each side; these were 19-French round Jackson-Pratt's.
I then closed the subcutaneous tissue using a running 2-0 Vicryl and we put another
drain just above the fascia and underneath the subcutaneous tissue and brought it out
a superior left upper quadrant stab incision. We then closed the skin with staples
and I tightened the retention sutures over plastic bridges and tightened these down
appropriately. The patient tolerated this procedure well.