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appendiceal abscess drainage and attempted appendectomy

Pediatric Posted Thu 08th of January, 2015 13:17:24 PM


Please help with following operative report. Should or can I code for an attempted appy with a drainage code?

PREOPERATIVE DIAGNOSIS: Acute perforated appendicitis with abscess.
POSTOPERATIVE DIAGNOSIS: Acute perforated appendicitis with abscess.

1. Laparoscopic drainage of appendiceal abscess.
2. Central venous catheter insertion with ultrasound and fluoroscopic guidance.

FINDINGS: There was a phlegmonous mass in the right lower quadrant that involved the cecum, appendix, terminal ileum, and the omentum. The perforation in the appendix appeared near the base. The inflammation was too intense to make out structures near the base of the appendix. An appendicolith was seen and retrieved near the base of the appendix. The abscess was well contained in that phlegmonous mass. The central line placed was a 5-French double-lumen 8 cm Spectrum catheter. It was placed in the right internal jugular vein by ultrasound and fluoroscopic guidance. The catheter tip was at the junction of the superior vena cava and right atrium by intraoperative fluoroscopy. Both lumens of the catheter aspirated blood easily and flushed easily as well.

TECHNIQUE: The patient was brought to the operating room where general endotracheal anesthesia was induced. The phlegmon was palpable in the right lower quadrant. The abdomen was prepped and draped with ChloraPrep solution. A time-out was done. Marcaine 0.25% with epinephrine was locally infiltrated at all port sites. A vertical incision was made through the umbilicus. A 12-mm Step port was inserted into the umbilical incision. The abdomen was insufflated with carbon dioxide gas. Under direct vision, 2 additional 5-mm Step ports were placed in the suprapubic and left lower quadrant areas. The omentum was adherent to the undersurface of the anterior abdominal wall in the right lower quadrant. This was gently dissected off the undersurface of the anterior abdominal wall with blunt dissection. The tip of the appendix was found. It was adherent to the terminal ileum and omentum. They were very stuck and therefore a LigaSure device was used to separate the omentum from the appendix. Gentle blunt dissection was used to separate the terminal ileum from the appendix. As this separation proceeded, the abscess cavity was entered. Purulent fluid drained from the abscess cavity. Some of the fluid was collected in a Lukens trap and sent for culture. Further dissection demonstrated that the inflammation near the base of the appendix was too intense to make out structures well. An appendicolith was seen in that area and was retrieved in an Endopouch. Satisfied that an attempt at appendectomy would be too treacherous given the degree of inflammatory change in that area, it was decided to back out and just drain the abscess. The right lower quadrant and the pelvis were irrigated with saline solution and suctioned until the effluent was clear. The omentum was placed over the appendix and cecum to contain any leak from the remaining perforation of the appendix. The ports were removed and the abdomen was deflated. The fascia at the umbilicus was reapproximated with interrupted 0 Vicryl suture. The skin edges at all port sites were reapproximated with skin glue.

Thank you!

SuperCoder Answered Fri 09th of January, 2015 11:51:26 AM

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