PREOPERATIVE DIAGNOSIS:
1. Suspected abdominal wall abscess
POSTOPERATIVE DIAGNOSIS:
1. Abdominal wall abscess
PROCEDURE:
1. Exploration of abdominal wall post op fluid collection, incidion and drainage of abdominal wall abscess
ANESTHESIA:
General
INDICATION FOR PROCEDURE:
This unfortunate 63y.o. lady underwent free flap reconstruction of her left arm wound with an abdominal donor site. She is quite noncompliant and has difficulty keeping postoperative dressing on appropriately. She has also been vaping nictoine. In clinic today, her abdominal incision was intact, but there was substantial erythema and likely abscess formation both around her drain site as well as the central abdominal incision. Our plan today is exploration of the fluid collection with incision and drainage.
OPERATIVE DETAILS:
After being seen by all team members and undergoing informed consent in the pre-operative area, the patient was identified and marked on the abdomen. When all team members were in agreement, she was wheeled to the operating room on a stretcher.
SCDs were connected to bilateral lower extremities and a verbal timeout to confirm correct patient, identity, site, and procedure were performed before induction of anesthesia.
When all team members were in agreement, the patient was transferred to the operating room table.
After induction of anesthesia, a Foley catheter was not placed. The patient was positioned in the supine position. she was appropriately padded at all pressure points for the anticipated duration of the case.
The abdomen was prepped and draped in the standard sterile fashion.
We began by widely reopening the central abdominal incision and dissecting down to the abdominal wall. A large purulent collection was encountered, and this was sent for culture. All necrotic tissue was excised and the cavity curetted. The old drain sites were also infected and were curetted. We then pulse irrigated all of these sites and dressed the wound with a VAC Veraflo.
After application of dressings, the patient was awoken from anesthesia without difficulty and transferred to the recovery room.
At the end of the case all needle, sponge, and instrument counts were correct x 2.
Intraoperative Fluids:
Per Anesthesia
EBL:
50 mL
Blood/Blood Products Transfused:
Per Anesthesia
Drains:
VAC
Specimens:
None
Complications:
None
Condition on Discharge from the operating room was stable
CPT: 35840 Exploration for Postoperative Hemorrhage, Thrombosis, or Infection; Abdomen
The provider reopens the abdomen to find and correct the source of bleeding, clotting, or infection after a previous operation.
ICD-10 : L02.211 – Cutaneous abscess of abdominal wall