JenReyn99
Guru
Patient had a sig resection the day before, and came back with anemia that was uncontrollable. The doc decided to re-open, and here's the notes:
The old trocar sites were reopened. The abdomen was systematically explored, and approximately 300 ml of clotted and non-clotted blood was removed from the peritoneal cavity. Bleeding was in the left upper quadrant. First I was concerned that may be a spleen injury. However, it was clear that there was no spleen injury. Rather, the bleeding was from the left mesocolon at a site wher I had revoced adhesions to omentum during the prior surgery. There were titanium clips in the vicinity. Additional titanium clips were placed for complete control of the very small arterial which was bleeding. After thoroughly irrigating and removing the remainder of the clot, the pelvis was noted to be full of blood. The anastamosis appeared to be intact. The patient tolerated the operation well.
Please help! I was thinking 49320, but that doesn't really cover the bleeding control. I have no idea. Thanks for the help! :0)
The old trocar sites were reopened. The abdomen was systematically explored, and approximately 300 ml of clotted and non-clotted blood was removed from the peritoneal cavity. Bleeding was in the left upper quadrant. First I was concerned that may be a spleen injury. However, it was clear that there was no spleen injury. Rather, the bleeding was from the left mesocolon at a site wher I had revoced adhesions to omentum during the prior surgery. There were titanium clips in the vicinity. Additional titanium clips were placed for complete control of the very small arterial which was bleeding. After thoroughly irrigating and removing the remainder of the clot, the pelvis was noted to be full of blood. The anastamosis appeared to be intact. The patient tolerated the operation well.
Please help! I was thinking 49320, but that doesn't really cover the bleeding control. I have no idea. Thanks for the help! :0)