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Thread: Left Groin Vascular Delay procedure

  1. #1

    Default Left Groin Vascular Delay procedure

    AAPC: Back to School
    I am a coder in an ASC and this procedure has been haunting me. This procedure is done before her TRAM flap reconstruction to insure optimal healing and flap survival.


    PREOPERATIVE DIAGNOSIS: Acquired right breast deformity status post right
    breast cancer.
    POSTOPERATIVE DIAGNOSIS: Acquired right breast deformity status post right
    breast cancer.
    PROCEDURE: Left groin vascular delay procedure.
    ANESTHESIA: MAC plus local (approximately 17 mL of a mixture of 2% lidocaine
    with epinephrine and 0.5% plain Marcaine).
    FLUIDS: Approximately 850 mL of Crystalloid.
    SPECIMEN: None.
    DRAINS: None.
    Condition to recovery room stable.
    FINDINGS: The thin patient with slightly different anatomy.
    IDENTIFICATION: The patient is a 64-year-old African American female with
    history of hypertension and right breast cancer. She was seen for initial
    consultation on 11/13/2006 for an immediate TRAM flap reconstruction. The
    patient refuses implant reconstruction. Because of possible skin involvement
    and locally advanced breast cancer, she underwent a right modified radical
    mastectomy by Dr. Tette on 11/17/2006 without any reconstruction. She is now
    status post chemotherapy and radiation therapy to the right breast and chest
    wall. She was seen for a second opinion by Dr.__________ on 3/14/2007. She
    then returned for a second visit evaluation on 7/30/2008. Her left mammogram
    on 12/14/2007 was negative. The patient presents for delayed right breast
    TRAM flap reconstruction at Holy Cross Hospital on 10/17/2008. She presents 1
    week earlier for the vascular delay procedure to insure optimal healing and
    flap survival. The procedure, alternatives, benefits, risks and
    complications were discussed including wound dehiscence and infection, pain,
    bleeding, etc. were discussed. The patient seems to understand and wished to
    DESCRIPTION OF PROCEDURE: After proper name band identification and marking
    of the correct operative location, the patient was brought to the operating
    table, placed in the supine position. After successful MAC anesthesia was
    obtained, the left lower quadrant abdominal and groin areas were prepped and
    draped in the usual sterile fashion. Local anesthetic was infiltrated. Of
    note, preoperative markings were performed in the standing upright position.
    The patient has a generous but slightly atrophic lower abdominal pannus.
    Using the 15-blade scalpel a transverse skin incision was made starting
    approximately 2 fingerbreadths above the midline pubic tubercle and 2
    fingerbreadths to the left. The incision was made and was approximately 4 cm
    wide. The deep dermis and the subcutaneous layers were divided with
    electrocautery. Because the incision was the low, the external oblique was
    divided as well as some of the internal oblique muscle to find the deep
    inferior epigastric vessels. However, this dissection was too lateral
    initially and the dissection then was carried more medial, dividing the left
    anterior rectus sheath with electrocautery. During this section which was
    carried to inferior, the transversalis fascia was divided area. There
    appeared to be resemblance of small bowel underneath. By looking slightly
    superior and lateral on the edge of the left rectus sheath, the deep inferior
    epigastric vessels were identified without much adipose layer covering. These
    were ligated proximally and distally with hemoclips and the central left deep
    inferior epigastric artery was divided with the Metzenbaum scissors after
    ligation proximally and distally with 2-0 silk and multiple hemoclips. The
    straddling venae comitantes veins were also ligated with interrupted 2-0 silk,
    but not cut. The central artery was divided with the Metzenbaum scissors.
    The wound was irrigated and closed in the few fascial areas with interrupted 2-
    0 Vicryl and a running 3-0 Vicryl for the fascia and the internal and external
    oblique layers laterally. The anterior rectus fascia was closed with running
    3-0 Vicryl. Scarpa's was closed with interrupted 2-0 Vicryl. The deep dermis
    was closed with interrupted 3-0 Caprosyn suture and the skin was closed with a
    running subcuticular 4-0 Caprosyn. The incision was then dressed with
    Mastisol, Steri-Strips and a gauze pressure dressing. Local anesthetic was
    infiltrated into the wound throughout the procedure. The patient tolerated
    the procedure well. Hemostasis was achieved by electrocautery throughout
    entire procedure. At the end all instrument, sponge and needle counts were

  2. #2
    Join Date
    Apr 2007


    its haunting me too...lol

  3. #3


    Quote Originally Posted by mbort View Post
    its haunting me too...lol
    After further research I came up with this code 37617. Would you agree?

  4. #4
    Join Date
    Apr 2007


    hmmm not convinced..Did you happen to check with the surgeons office to see what they are using?
    I dont like doing that but sometimes its helpful.

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