Case -T9-1B OPERATIVE REPORT, TRACHEOSTOMY

Essay

Case
-T9-1B OPERATIVE REPORT, TRACHEOSTOMY
This service was provided during the postoperative period for a previous related procedure conducted by the same surgeon.
LOCATION: Inpatient, Hospital
PATIENT: Duane Monsonbratten
PHYSICIAN: Gregory Dawson, MD
ATTENDING PHYSICIAN: Gregory Dawson, MD
PREOPERATIVE DIAGNOSIS: Acute respiratory failure
POSTOPERATIVE DIAGNOSIS: Acute respiratory failure
PROCEDURE PERFORMED: Tracheostomy
ANESTHESIA: General
INDICATIONS FOR SURGERY: The patient is a 62-year-old Caucasian male who has pneumonia. The patient has been on a ventilator for over 2 weeks and appears to require long-term ventilator. The patient is undergoing tracheostomy for this purpose.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the usual manner. A vertical incision was made along the anterior border of the neck. The patient has a very short neck; therefore, it made the operation much more difficult. Dissection was carried down to the trachea using Bovie cautery. The patient had multiple small vessels in the operative area that had to be either bovied or ligated with interrupted 3-0 silk sutures or stick tied with 3-0 silk sutures. After completion of the dissection down to the trachea, the first ring was identified; the second and third rings were also identified. 0 silk stay sutures were placed on either side of the trachea through the second and third rings. An incision was then made in the second and third rings, also creating a low pocket so that a #8 Shiley trach tube could be placed. After the opening was made, the endotracheal tube was pulled back so that the tracheostomy tube through the neck could be placed. Once it was in place, it was hooked to ventilation. The stay sutures were left in place. The tracheostomy tube was then tied around the trachea opening. The skin was injected with 0.5% Marcaine with epinephrine; a total of 8 cc was used. The patient tolerated the procedure and returned to the intensive care unit in stable condition.
T9-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________