Debridement of wound left anterior aspect left thigh.
Assign the CPT procedure codes
21. PROCEDURE PERFORMED:
1. Debridement of wound left anterior aspect left thigh.
2. Split thickness skin graft from the right thigh to the medial aspect of the left leg measuring 20 x 10 cm.
3. Split thickness skin graft from the right thigh to the lateral aspect of the left lower leg measuring 20 x 7 cm.
4. A split thickness skin graft from the right thigh to the left lateral thigh measuring 24 x 11 cm.
5. Split thickness skin graft from the right thigh to the left anterior thigh measuring 13 x 1.5 cm.
ANESTHESIA: General endotracheal anesthesia
ESTIMATED BLOOD LOSS: Negligible
DESCRIPTION OF PROCEDURE: The legs were prepped with Betadine scrub and solution, draped in a routine sterile fashion. The anterior left thigh wound was debrided and split thickness skin grafts measuring 10,000th to 11,000th of an inch thick were taken from the right thigh, meshed with the 3:1 ratio mesher, and applied to all of the defects mentioned above of the left leg in the measurements noted. They were stapled to the wounds, mostly on the edges, and dressings then consisted of Xeroform, Kerlix fluffs, Kerlix roll, Kling and an Ace bandage. Estimated blood loss was negligible. Scarlet red was applied to the donor site. The patient tolerated the procedure well and left the area in good condition.
22. PREOPERATIVE DIAGNOSIS: Postoperative bleeding from sacral wound. POSTOPERATIVE DIAGNOSIS: Same.
SURGICAL FINDINGS: One very active bleeder and one less active bleeder along the wound margin.
SURGICAL PROCEDURE: Wound exploration and cauterization of two bleeders of the wound edge.
ANESTHESIA: Local with plain 1% Xylocaine, approximately 10 cc along each suture line.
DESCRIPTION OF PROCEDURE: The patient was turned in the prone position and we injected more local anesthesia, 1% Xylocaine and 1:100,000 epinephrine having injected some in the Recovery Room. I cauterized the very active bleeder that was noted, and saw one more less active bleeder along the suture line. Surgicel was in place at the depths of the wound in a pool of topical thrombin that we had placed in the proximal aspect of the wound from where the bleeding came. I then saturated a 2-inch vaginal gauze packing with topical thrombin and packed this in the wound followed by one box of Kerlix Fluffs. The wound was then dressed with Elastoplast.
23. PROCEDURE(S) PERFORMED: Debridement and split-thickness skin graft reconstruction of the right foot wound, total of 3 x 4 cm.
PROCEDURE: Joni was brought to the operating room and after a local anesthetic was administered; her right lower extremity was prepped and draped in the usual sterile fashion. Using a 15-blade scalpel, the margins of the wound were debrided back to healthy bleeding tissue. The base of the wound was debrided using a small curette to remove the top layer of granulation tissue. Once the wound was debrided, the wound was irrigated with copious saline using a pulse lavage irrigator. The final defect measured 3 x 4 cm. An appropriately-sized split-thickness skin graft was harvested at 11/1000 thickness from the right anterior thigh using the Padgett dermatome. The graft was meshed and placed onto the recipient bed using interrupted 5-0 fast-absorbing suture. The donor site was then converted into an elliptical incision of 4 cm using a 10-blade scalpel and then closed using interrupted 4-0 Monocryl deep dermal suture followed by a 4-0 Monocryl running subcuticular suture and Dermabond. The dressing was placed on the right foot consisting of Xeroform, fluffs, ABD, Kerlix, and an Ace wrap. She was discharged to Recovery in stable condition.
24. PROCEDURE(S) PERFORMED: Debridement of right posterior thigh and popliteal fossa and split-thickness skin graft reconstruction, total 22 cm by 16 cm.
PROCEDURE: Floyd was brought to the operating room, and, after general anesthetic was administered, he was placed in the prone position and prepped and draped in the usual sterile fashion. Using a free Padgett dermatome blade, the wound was completely excised down to healthy bleeding tissue. In the area of the popliteal fossa, the excision was taken down to healthy soft subcutaneous tissue. Hemostasis was obtained with electrocautery. The wound was irrigated with copious saline. The final defect measured 22 cm by 16 cm. An appropriately sized split-thickness skin graft was harvested by taking 2 strips of skin at 10/1000 thickness from the right lateral and anterior thigh. The graft strips were meshed at 1 to 1.5 and placed on the recipient site using skin staples.
The wounds were dressed with Xeroform, fluffs, ABDs, Kerlix, and an Ace A posterior fiberglass splint was also placed underneath the Ace wrap. He was discharged to Recovery in stable condition.
25. PROCEDURE(S) PERFORMED: Debridement of wounds of the right leg with medial gastrocnemius muscle flap and skin graft reconstruction of the left leg total skin graft surface area of 28 x 7 cm.
FINDINGS: Necrotic tibialis anterior musculature requiring debridement and medial gastrocnemius reconstruction. Verbal consent from his mother was taken by the phone intraoperatively.
PROCEDURE: Scott was brought to the operating room and after general anesthesia was administered, he was placed in the left lateral decubitus position and his left leg as well as his right thigh were prepped and draped in the usual sterile fashion. Inspection was made of the wounds and it was evident that the tibialis anterior musculature covering the tibia was grayish and noncontractile. Using a #10 blade scalpel, the tibialis anterior muscle was debrided back to healthy vascular tissue, which left the bone exposed. Because of soft tissue inadequacy, it was determined that a medial gastrocnemius muscle flap was most appropriate, for covering the bone and the distal portion of the internal hardware, left leg wound. Consent was taken verbally over the phone after explaining in great detail to the family the muscle flap itself. Using a #10 blade scalpel, the fasciotomy incision through the skin was extended proximally and distally to expose the gastrocnemius muscle. The midline was identified and, using electrocautery, the muscle itself was incised at its margins down to the soleus musculature. The flap was carefully elevated off the soleus musculature. Blunt and sharp dissection was carried out superiorly to allow mobilization of the muscle. The deep fascia was scored with a #10 blade scalpel to allow greater mobilization of the muscle. A #10 blade scalpel was then used to incise the skin bridge, extending from the medial fasciotomy region over to the anterior tibial area. The muscle flap then lay without tension over the distal portion of the hardware and over the tibia itself. The flap was then set using interrupted 3-0 Vicryl suture. The flap appeared to be viable once in set. The final defects were then measured for a total of 28 x 7 cm. Appropriately-sized split-thickness skin grafts were harvested from the right anterior and lateral thigh at 22/1000 thickness. The donor site was dressed with Tegaderm dressings. The left leg wounds were irrigated with copious saline using a pulsed lavage irrigator. The grafts were fixed to the recipient sites using skin staples. Dressings consisting of Xeroform, fluffs, ABDs, Kerlix, and an Ace wrap were placed and he was discharged to recovery in stable condition.
26. PROCEDURE(S) PERFORMED: Debridement and layered closure of sacral pressure sore, total 6 cm, Stage III.
PROCEDURE: Hazel is brought to the operating room and after a general anesthetic was administered she was placed in the prone position and prepped and draped in the usual sterile fashion. Immediate examination revealed a moderate amount of necrotic tissue at the base and the margins of the wound. There was no gross evidence of infection. The wound margins were excised with # 10 blade scalpel at the skin and then electrocautery at the lateral margins and the base. The sacrum was not exposed. Debridement was carried out back to healthy, viable, bleeding tissue. The wound was irrigated with 2 L of sterile saline using a pulse lavage irrigator and then using 3-0 Vicryl sutures in interrupted fashion. The wound was closed in multiple layers. Finally, Dermabond was used to seal the wound and skin staples were placed once the Dermabond was dry. A dressing consisting of ABD was placed and she was discharged to recovery in stable condition.
Pathology Report Later Indicated: Necrotic tissue.
27. PROCEDURE(S) PERFORMED: Left free myocutaneous TRAM flap to the left leg.
INDICATIONS: This is a patient who had a left lower extremity trauma with a failed latissimus dorsi myocutaneous flap. The patient had that flap performed. It was successful and fine for 3 days. There was a venous thrombosis and exploration was not successful in salvaging the flap and it was debrided. She returns today for further reconstruction.
PROCEDURE: In conjunction with my partner, Dr. Sanchez, we operated simultaneously to expedite this patient’s surgery. I performed harvest of the left free myocutaneous TRAM flap. Beginning with preoperative markings extending from the upper pubic region to the umbilicus, elliptical skin markings were made in the lower abdomen. The upper and lower incisions were made, and the right superior inferior epigastric vein was identified and preserved. This having been done, the upper and lower skin incisions were made down to abdominal wall fascia, and the flaps raised bilaterally just above the external oblique fascia to the lateral row of vascular perforators coming through the rectus abdominis muscle. Identification and evaluation of the perforators indicated that the left-sided perforators were more robust, and so the right-sided perforators were ligated through to the midline. Adequate medial and lateral row perforators were identified on the left side and the anterior rectus sheath opened in a fascia-preserving fashion at the level of the lateral and elliptical portion of fascia was then incised and medial row perforators, and the fascia opened to fully expose the rectus muscle on the left side. This having been done, the rectus muscle was elevated off of the posterior rectus sheath, transected superiorly and harvested in a cranial to caudal fashion down to the take-off towards the iliac vessels of the deep inferior epigastric artery. The deep inferior epigastric artery and 2 veins were identified, separated and vessel loops placed around, and then the inferior margin of the rectus muscle transected.
When Dr. Sanchez indicated that he had recipient vessels adequately prepared for microvascular transfer, the deep inferior epigastric artery was ligated followed by the 2 deep inferior epigastric veins. A heparin irrigator was placed into the artery, and the flap rinsed of any blood with heparinized saline. The flap was then handed to Dr. Sanchez who proceeded with leg reconstruction, and I returned my attention to the abdominal donor site. Meticulous attention was paid to hemostasis, and a piece of Prolene mesh trimmed to fit the patient’s fascial defect, and used an inlay mesh graft. The fascia was closed in a fascia-to-fascia fashion with the Prolene mesh internally placed and 0 Ethibond suture used to close the fascial defect in an interrupted figure-of-eight fashion.
Following closure of the anterior rectus sheath, the abdomen appeared to be extremely stable structurally, and the patient was placed into a reflexed position. Two 15-French Blake drains were placed through the pubic area into the abdominal donor site, and an upper abdominal flap was elevated in an abdominoplasty fashion.
The upper abdominal flap was closed to the lower incision with towel clips, and 2-0 Ethibond suture used to close Scarpa fascia in an interrupted fashion. 3-0 PDS suture was then used to close the deep dermis followed by 3-0 PDS suture in a running subcuticular fashion used to perform final closure. Dermabond was used to close the abdominal wound and 3-0 nylon suture used to fix the JP drains in position.
A bulky dressing and abdominal binder were placed around the abdomen at the conclusion of the procedure. Blood loss from this portion of the operation was quite minimal. Patient tolerated the procedure well and was transferred to the recovery area in good condition.
28. PROCEDURE(S) PERFORMED:
1. Excision of squamous cell carcinoma of the forehead total 3.5 cm.
2. Partial layered closure 1.5 cm.
3. Full thickness skin graft total 3 cm in diameter.
PROCEDURE: Marla was brought to the operating room. After local anesthetic was administered, her face and her neck were prepped and draped in the usual sterile fashion. Using a 15-blade scalpel, the lesion was incised with a wide margin of normal-appearing tissue down to the galea. The lesion was excised at the subgaleal plane. There did not appear to be ulceration through the galea grossly. The specimen was marked with a suture at 12 o’clock superior and sent for frozen section pathology which confirmed the margins were clear. Using interrupted 4-0 Monocryl suture, the deep dermis was reapproximated medially and laterally as much as the wound margins would allow. The remaining defect then measured 3 cm in diameter. An appropriately sized full thickness skin graft was harvested from her left neck using a fresh 15-blade scalpel. The graft was defatted with sharp scissors and placed on the recipient site. It was affixed into position using interrupted 5-0 fast-absorbing suture. A tie-over dressing consisting of 5-0 nylon, Xeroform, and cotton balls was placed. The donor site was reapproximated with a running 4-0 Monocryl subcuticular suture and 5-0 fast-absorbing suture to reapproximate the epidermis, and Dermabond dressing was placed. She was discharged to the care of Dr. Almaz who is performing a total knee on the left side today.
Pathology Report Later Indicated: Squamous cell carcinoma of the skin of the forehead.
29. POSTOPERATIVE DIAGNOSIS: Multiple sinus tracts, one extending inferiorly about 7 x 3 cm in diameter, one extending to the right approximately 4 x 3 cm, and one extending to the left for about 3 cm.
SURGICAL FINDINGS: As above, plus granulation tissue present in a capsule of multiple sinus tracts. Sinus tracts measured a total of about 15 x 8 cm in their total dimensions.
SURGICAL PROCEDURE: Partial unroofing of sinus tracts through subcutaneous skin.
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The patient was intubated and turned in the prone position. A probe was inserted in the sinus cavity, and dissection was carried down to this. I encountered a piece of chronically infected granulation tissue coming out of a hole, in which I stuck the probe, but this continued for a distance longer than the probe and accordingly, I put my finger in this and this extended down the length of my index finger (i.e., about 7-8 cm by about 3 cm in width). I left this intact, because this would necessitate extensive dissection and we have no blood on this patient at this time. We then unroofed two other sinus cavities, and packed this open with 2-inch vaginal packing and applied a dressing and Kerlix plus an Elastoplast. Estimated blood loss: 25 cc. The patient seemed to tolerate the procedure well and left the operating room in good condition.
Pathology Report Later Indicated: Granulation tissue with inflammation.
30. SURGICAL PROCEDURES:
1. Sentinel node biopsy, left submandibular region.
2. Wide-excision (1 centimeter) of desmoplastic malignant melanoma, left side of upper lip with through-and-through excision and 1 centimeter margins on all sides.
ANESTHESIA: General endotracheal with supplementary 2 cc of 1 percent Xylocaine and 1:800,000 Epinephrine.
SURGICAL FINDINGS: The patient had a scar of the upper lip and a 5 millimeter linear, pigmented lesion near the mucosal junction. There was one submandibular lymph node identified that appeared to be benign. No occipital or posterior submandibular lymph nodes were identified despite assiduous search.
DESCRIPTION OF PROCEDURE: Following injection of radioactive dye in the Radiology Department, the patient was sent to the operating room where the face and neck were prepped with Betadine scrub and solution and draped in a routine sterile fashion. The sites that had been identified in Radiology were noted, and on the mastoid area, I detected 100 on the probe externally. I explored this, but when I got inside, I was unable to reproduce the external reading despite a vigorous exploration of the mastoid area and splitting of the sternocleidomastoid muscle over the site where most of the probe activity was evident. We made about a 3 centimeter incision in this area and explored it thoroughly in all areas indicated. I thought on occasion I palpated a lymph node, but upon deep dissection, it was noted that this was simply another fiber of the sternocleidomastoid muscle, and we abandoned this after a search of about 15 minutes. In the submandibular area, an incision was made, and activity was evident. The skin in the posterior mandibular area had a reading of 13 with an in vivo reading of 63. However, the ex vivo was only approximately 7 on the specimen itself. It may have been too small to have caused any reactivity. The background was 26 following removal of a small lymph node which was less than 1 centimeter diameter. No anterior mandibular lymph node was ever identified. Also, it should be noted that at no time did I, other than the small lymph node we removed, palpate lymphadenopathy in the mesenteric muscle region or in the region of the external maxillary artery which crossed the marginal mandibular nerve. I then marked out a margin of 1 centimeter around the previous scar, and in so doing I noted that included within this resection was a 5 millimeter linear pigmented lesion. This was excised like a wedge resection of the lower lip, and bleeding of the coronal arteries were clamped and ligated with 4-0 Vicryl. I then began closure of the mucosa, lining up the mucocutaneous junction and lining up the vermillion where it meets the white roll. After completion of the mucosal closure, the musculature was brought together. The orbicularis oculi musculature was brought together with 4-0 Vicryl suture, and interrupted 5-0 Prolene was used to reapproximate the skin. There was no evidence of residual tumor within the specimen submitted. A silk suture tagged the lip side of the specimen. Antibiotic ointment was applied, and 4 by 4 was used to cover the incision. The patient tolerated the procedure well and left the area in good condition.
Pathology Report Later Indicated: Malignant melanoma of the lip with no evidence of residual tumor within the lymph nodes.
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