Case -T5-1A OPERATIVE REPORT, DEBRIDEMENT

Essay

Case
-T5-1A OPERATIVE REPORT, DEBRIDEMENT
LOCATION: Outpatient, Hospital
PATIENT: Glenn Mustgroven
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Fat necrosis, wound of left buttock
POSTOPERATIVE DIAGNOSIS: Fat necrosis, wound of left buttock
SURGICAL PROCEDURE: Debridement of fat necrosis (this is degeneration of the skin), complex wound, with closure of complex 15-cm (centimeter) wound
ANESTHESIA: General endotracheal
SURGICAL FINDINGS: There is an area of about 4 6 centimeters diameter fat necrosis in the depth of the wound. The wound itself was initially about 3 centimeters in diameter.
ESTIMATED BLOOD LOSS: Negligible
DESCRIPTION OF PROCEDURE: The patient's left buttock was prepped with Betadine scrub and solution and draped in a routine sterile fashion. The area was extended to reveal about a 4 6 cm area of fat necrosis, which was debrided and submitted for permanent sections. Bleeding was electrocoagulated, and the wound irrigated with a liter of Ringer's lactate. A #10 Jackson-Pratt drain was placed in the depth of the wound and brought out through the wound, suturing it to the wound with 0 Monocryl, closing the wound with subcuticular 2-0 Monocryl and a few horizontal mattress sutures of 2-0 Monocryl. Dressings consisted of Xeroform, Kerlix fluffs, and Elastoplast. The patient tolerated the procedure well and left the operating room in good condition.
PATHOLOGY REPORT LATER INDICATED: Necrotic fat tissue
T5-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________