sandy06
Networker
DIAGNOSIS:
Ruptured vertebral body.
POSTOPERATIVE DIAGNOSIS:
Ruptured vertebral body.
PROCEDURE PERFORMED:
1. Right posterior lateral thoracotomy for exposure of vertebral body
for T6, T7, and T8 for the neurosurgeons.
2. Primary closure of a thoracotomy incision over a 28-French
straight chest tube.
SURGEON:
Dr.
ASSISTANT:
Dr.
PROCEDURE IN DETAIL:
Briefly, patient identified in the preop recovery room, placed her on
the table in the supine position. At this point, generalized
double-lumen tube intubation, Foley catheter was replaced, including
an A-line and a central line. Patient was then placed in left
decubitus position with all bony prominences padded. At this point,
prepped and draped in sterile fashion. She was brought to fluoroscopy
at the T7 range. At this point, a posterior lateral thoracotomy
incision was created just below the tip of the xiphoid in the
posterior lateral aspect in the mid axillary line posteriorly and
into the subcutaneous tissue with the Bovie cautery, achieved
hemostasis. At this point, the latissimus muscle, as well as serratus
muscle was transected with the Bovie cautery and through to the
muscle layers without any difficulty, achieving hemostasis. At this
point, the intercostal muscles were identified. We were able to enter
into the 6th intercostal space. Once entered into the intercostal
space with the lung deflated, we were able to extend the incisions
both anteriorly and posteriorly. At this point, a retractor was
inserted in two separate areas, extended the incision and identifying
the deflated lung. His lung was moved medially with the help of
retractors. At this point, we were able to expose the spine. We were
able to expose T5 through T9 without any difficulty. No diaphragm
stitch was required, and at this point, the exposure was adequate for
the neurosurgeons and they went ahead and proceed with their fusion
of the vertebral bodies with a cage insertion. Once they had been
completed we were called back into the room for closure. Hemostasis
was identified. The area was copiously irrigated with warm saline
solution. A 28-French chest tube was inserted through separate stab
incision in the midaxillary line, just anterior to the pubic rim.
This was done without any difficulty. The chest tubes connected to a
Pleur-Evac and measured at 20 cm of water. (____) with hemostasis
identified using number 2 pericostal sutures in a figure-of-eight
fashion, the ribs were reapproximated. Once the ribs were
reapproximated using 0 Vicryl suture, we were able to reapproximate
the muscle bundles, both the posterior and anterior muscle sheaths
were able to be reanastomosed, both the serratus level and at the
latissimus level. Once the muscles were reapproximated, the
subcutaneous tissue was closed with 2-0 Vicryl running subcutaneous
to closure in two-layer fashion and 3-0 Monocryl at the skin.
Dermabond was used at the skin level. Chest tube was connected to
Pleur-Evac. The patient was placed back in a supine position and
tolerated procedure well. A chest x-ray will be obtained, and the
patient is hemodynamically stable and tolerated the procedure well.
Can someone please help me with this Op Report, I think I have the right code but am not too sure,
32100
Ruptured vertebral body.
POSTOPERATIVE DIAGNOSIS:
Ruptured vertebral body.
PROCEDURE PERFORMED:
1. Right posterior lateral thoracotomy for exposure of vertebral body
for T6, T7, and T8 for the neurosurgeons.
2. Primary closure of a thoracotomy incision over a 28-French
straight chest tube.
SURGEON:
Dr.
ASSISTANT:
Dr.
PROCEDURE IN DETAIL:
Briefly, patient identified in the preop recovery room, placed her on
the table in the supine position. At this point, generalized
double-lumen tube intubation, Foley catheter was replaced, including
an A-line and a central line. Patient was then placed in left
decubitus position with all bony prominences padded. At this point,
prepped and draped in sterile fashion. She was brought to fluoroscopy
at the T7 range. At this point, a posterior lateral thoracotomy
incision was created just below the tip of the xiphoid in the
posterior lateral aspect in the mid axillary line posteriorly and
into the subcutaneous tissue with the Bovie cautery, achieved
hemostasis. At this point, the latissimus muscle, as well as serratus
muscle was transected with the Bovie cautery and through to the
muscle layers without any difficulty, achieving hemostasis. At this
point, the intercostal muscles were identified. We were able to enter
into the 6th intercostal space. Once entered into the intercostal
space with the lung deflated, we were able to extend the incisions
both anteriorly and posteriorly. At this point, a retractor was
inserted in two separate areas, extended the incision and identifying
the deflated lung. His lung was moved medially with the help of
retractors. At this point, we were able to expose the spine. We were
able to expose T5 through T9 without any difficulty. No diaphragm
stitch was required, and at this point, the exposure was adequate for
the neurosurgeons and they went ahead and proceed with their fusion
of the vertebral bodies with a cage insertion. Once they had been
completed we were called back into the room for closure. Hemostasis
was identified. The area was copiously irrigated with warm saline
solution. A 28-French chest tube was inserted through separate stab
incision in the midaxillary line, just anterior to the pubic rim.
This was done without any difficulty. The chest tubes connected to a
Pleur-Evac and measured at 20 cm of water. (____) with hemostasis
identified using number 2 pericostal sutures in a figure-of-eight
fashion, the ribs were reapproximated. Once the ribs were
reapproximated using 0 Vicryl suture, we were able to reapproximate
the muscle bundles, both the posterior and anterior muscle sheaths
were able to be reanastomosed, both the serratus level and at the
latissimus level. Once the muscles were reapproximated, the
subcutaneous tissue was closed with 2-0 Vicryl running subcutaneous
to closure in two-layer fashion and 3-0 Monocryl at the skin.
Dermabond was used at the skin level. Chest tube was connected to
Pleur-Evac. The patient was placed back in a supine position and
tolerated procedure well. A chest x-ray will be obtained, and the
patient is hemodynamically stable and tolerated the procedure well.
Can someone please help me with this Op Report, I think I have the right code but am not too sure,
32100
Last edited: