mfournier
Networker
Hello Everyone:
Would someone be able to take a look at this op note and let me know what you think? I don't think this is 44604 maybe 49320? This was an outpatient so 44604 would not fly.
FINDINGS: A small less than 1 cm surface adjacent to the rectosigmoid junction in the retroperitoneum on the left side was oozing which was brought under hemostasis using a combination of electrocautery hook, LigaSure and Floseal. Good hemostasis at the end of the procedure.
INDICATIONS:
I was called into the operating room by Dr. XX when she was doing laparoscopic bilateral salpingo-oophorectomies for hydrosalpinx on the left side.
DESCRIPTION OF PROCEDURE:
Patient was already timed out, anesthetized, the procedure was almost completed when there was a wheezing noted on the left side next to the rectosigmoid junction and retroperitoneum.
There was adhesions posterior to the uterus, sigmoid colon, rectum. There was a lysis of adhesions and bilateral salpingo-oophorectomy which was performed already at the time of my participation in the surgery. On visual examination, there was a scar tissue with a charred tissue next to it from ligature, at the raw surface which was oozing blood. This was on the left side adjacent to the rectosigmoid junction could be a possible serosal tear or retroperitoneal tissue. It was superficial, minimal, therefore I utilized a LigaSure but it was very superficial and was difficult to grasp with the LigaSure. So, I utilized electrocautery hook and cauterized the bleeding surface on the left side of the sigmoid colon next to the previous scar tissue and retroperitoneal tissue. The bleeding completely stopped. Floseal was utilized to further reinforce the hemostasis in this area.
Patient tolerated the procedure very well.
Thank you
Would someone be able to take a look at this op note and let me know what you think? I don't think this is 44604 maybe 49320? This was an outpatient so 44604 would not fly.
FINDINGS: A small less than 1 cm surface adjacent to the rectosigmoid junction in the retroperitoneum on the left side was oozing which was brought under hemostasis using a combination of electrocautery hook, LigaSure and Floseal. Good hemostasis at the end of the procedure.
INDICATIONS:
I was called into the operating room by Dr. XX when she was doing laparoscopic bilateral salpingo-oophorectomies for hydrosalpinx on the left side.
DESCRIPTION OF PROCEDURE:
Patient was already timed out, anesthetized, the procedure was almost completed when there was a wheezing noted on the left side next to the rectosigmoid junction and retroperitoneum.
There was adhesions posterior to the uterus, sigmoid colon, rectum. There was a lysis of adhesions and bilateral salpingo-oophorectomy which was performed already at the time of my participation in the surgery. On visual examination, there was a scar tissue with a charred tissue next to it from ligature, at the raw surface which was oozing blood. This was on the left side adjacent to the rectosigmoid junction could be a possible serosal tear or retroperitoneal tissue. It was superficial, minimal, therefore I utilized a LigaSure but it was very superficial and was difficult to grasp with the LigaSure. So, I utilized electrocautery hook and cauterized the bleeding surface on the left side of the sigmoid colon next to the previous scar tissue and retroperitoneal tissue. The bleeding completely stopped. Floseal was utilized to further reinforce the hemostasis in this area.
Patient tolerated the procedure very well.
Thank you