Case -T7-2A OPERATIVE REPORT, APPENDECTOMY

Essay

Case
-T7-2A OPERATIVE REPORT, APPENDECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Sally Road
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Acute appendicitis
POSTOPERATIVE DIAGNOSIS: Acute appendicitis
OPERATIVE PROCEDURE: Open appendectomy
FINDINGS: The appendix was acutely inflamed but not perforated. There was a little bit of purulent fluid in the pelvis.
PROCEDURE IN DETAIL: After good general endotracheal anesthesia, 10 cc of Marcaine was administered about McBurney's point. A Rockey-Davis incision was made, and dissection was carried down to the sternal oblique fascia. This was incised. Then, using a muscle-sparing technique, the muscle was divided. The peritoneum was identified and incised. The abdomen was entered. The appendix was mobilized and brought up into the wound. The mesoappendix was divided, and the appendix was transected at the base after placing a tie at the base of the appendix. After this, the appendiceal stump was buried using a piece of epiploicae fat that was adjacent and covering it with a serosal stitch. Next, the pull-tip sucker was placed in the pelvis, and a tiny bit of fluid came back. We did not irrigate the abdomen. The peritoneum was then closed. A single suture was placed in the muscle itself to approximate dead space; then the fascia was closed with 3-0, and the skin was closed with 4-0 Vicryl. Steri-Strips and sterile dressings were applied. After the peritoneum was closed, the layers were irrigated in succession as we closed the wound. The patient tolerated the procedure well. The remaining 20 cc of Marcaine were infiltrated into the muscle and the skin. She was returned to the recovery room in good condition.
T7-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________