Can you help with this??? 61700 is aneurysm clipping but this seems more complicated...

PREOPERATIVE DIAGNOSIS: Ruptured anterior communicating artery aneurysm.
POSTOPERATIVE DIAGNOSIS: Ruptured anterior communicating artery aneurysm.
1. Left craniotomy for aneurysm clipping.
2. Right frontal intracranial pressure monitor placement.
ASSISTANT: neurosurgeon, needed during the
critical portions of the case for help with retraction and dissection as
well as control of hemorrhage during the aneurysm clipping. This was
needed in spite the fact that a resident was available.
ANESTHESIA: General with endotracheal intubation.
COUNTS: Sponge and needle counts correct x 2.
DETAILS OF THE PROCEDURE: The patient was brought to the operating room,
previously intubated. Lines were placed. The left side of her head was
clipped and sterilely prepped and draped in the usual fashion. Her head
was placed in a Mayfield headholder and a curvilinear incision was made
from the zygoma to the frontal region on the left. Subcutaneous tissue was
dissected using electrocautery. The Rainey clips were applied. The
temporalis muscle was incised using electrocautery and dissected forward
using a periosteal elevator. Pterion was exposed. Scalp hooks were placed
to hold the skin in place. Several bur holes were drilled and the dura
beneath was stripped using a Penfield 3. A craniotome bit was used to
connect the bur holes and remove a bone flap. During this, the dura was
lacerated. The brain was also very swollen and extended out of the dura.
At this time, the mannitol which had been previously administered had not
created a urinary response. Lasix was added without much of a response.
This was likely due to her kidney failure. A frontal ventriculostomy was
placed under direct visualization of the cortex and drained spinal fluid
with some relief of the pressure. A Budde halo was placed and
self-retaining retractors were placed to elevate the frontal lobe and
expose the optical carotid triangle. The brain was somewhat relaxed after
this and the Budde halo was placed to aide with self-retaining retractors.
The microscope was brought in. At this point,
Dr. scrubbed in to the case. The optical carotid triangle was
found. The left frontal lobe was elevated and a gyrus rectus resection was
performed to expose the anterior cerebral artery as it was initially
thought to be the A1 segment. Dissection of the subarachnoid space and the
surrounding hemorrhage was done. Multiple branches were identified and
what appeared to be a frontal polar branch was identified. It was very
difficult to find the aneurysm or most of the vessels. Resection distal
along the artery was performed and the opposite A2 segment was picked up
with significant brain retraction There was a laceration to the underlying
left frontal lobe and temporal tip. This created bleeding, which made it
difficult for visualization. We then tried to follow the vessels
proximally. As we did this, the ipsilateral A1 segment was identified, and
then the aneurysm dome at the anterior communicating artery segment. The
neck was dissected out very easily and clips were sized. A Sugita straight
titanium clip that was 7 mm was sized and as additional dissection was
done, the aneurysm was ruptured. This created a significant amount of
blood flow with both surgeons aspirating of maintain view of the aneurysm.
The clip was placed across the base which stopped the bleeding. Total
blood was 400 mL, none of which was after this point. The patient was not
transfused as a result of this. Doppler was used to confirm flow in the
distal vessels and hemostasis was achieved of the frontal lobes where they
had been contused using Surgicel and Gelfoam. The retractors were removed.
Once hemostasis was achieved, it was noted that the dura could not be
reapproximated completely, and the brain was still herniating out of the
craniotomy site to a certain extent. Dura Repair synthetic dura was placed
underneath the existing the dura and a couple tacking sutures were placed.
This was not a watertight closure. The bone flap was then replaced with 3
straight cranial plates. The temporalis muscle was then reapproximated
using 2-0 Vicryl sutures. The galea was reapproximated using 2-0 Vicryl
suture. The skin was closed with staples. The right frontal region was
then sterilely prepped and draped in the usual fashion after clipping the
head. An incision was made in the scalp. A twister was used to place a
bur hole. The Camino draining ventricular bolt was then placed after
incising the dura. No CSF was obtained. Initial ICP was 17. It was not
attached to a drainage bag. It was placed to the cranial pressure monitor
and was sterilely dressed in the usual fashion. The patient was returned
to the intensive care unit in stable condition.