SURGICAL OP REPORT # 15
DIAGNOSIS:Pericardial effusion - serous fluid.
OPERATION:Extraperitoneal pericardial window.
ANESTHESIA: General endotracheal anesthesia.
FINDINGS:Greater than 100 ml of clear yellow fluid within the pericardial sac. No evidence of blood within the pericardial sac.
PROCEDURE:Patient was brought to the operating room. He was prepped and draped in sterile fashion. We began by demarcating the pertinent landmarks including the xiphoid. We planned our incision in a vertical fashion 5 cm in length below the xiphoid.Scalpel was used to go through the skin and the subcutaneous tissues as well as to the underlying fascia. Once this was accomplished, we used blunt dissection in a cranial direction beneath the sternum. We were able to identify the extraperitoneal diaphragm. This was grasped with two Allis clamps and incised with a Metzenbaum scissors. This revealed the pericardium. The pericardium was grasped with two Allis clamps. It was opened with a Metzenbaum scissors. There was immediate expression of greater than 100 ml of clear serous fluid. This was suctioned. There was no evidence of intrapericardial hemorrhaging. The diaphragm was repaired with a single figure-of- eight stitch using a 3-0 Vicryl suture. This was followed by closure of the fascia with a 1-0 PDS running suture followed by closure of the skin with a 4-0 Biosyn in a subcuticular fashion.Sponge and equipment counts were correct at the end. Patient was brought to the Post Anesthesia Care Unit for recovery prior to disposition to the Surgical Intensive Care Unit.
This post has 4059 feedbacks awaiting moderation...
Public forum for coding surgical op reports and discussing surgical coding issues.