Gary I. Sanchez, M.D.
PREOPERATIVE DIAGNOSIS: Necrotizing wound infection, one week status post Cesarean section.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Wide wound exploration; excision of necrotic skin and subcutaneous tissue; debridement of abscesses. Frozen section obtained intraoperatively revealed a mixed picture of granulation tissue, inflammation, and necrotic tissue. The necrosis did not extend to the edge of resection. The edge of resection was viable.
PROCEDURE: After good general endotracheal anesthesia, the
patient was prepped and draped in the usual sterile fashion. The
entire previous C-section incision was opened from side-to-side,
and the necrotic skin edges were trimmed away. Specifically, there
was a 6 by 6 cm central portion of grossly necrotic tissue that was
debrided away. The subcutaneous tissue beneath this was clearly
necrotic, and this was also debrided away. Skin edges on both sides
were debrided away until there was bleeding, viable tissue noted.
The incision was extended laterally as there was infection that had
tracked laterally on both sides, and abscess cavities were
uncovered here. All clearly necrotic tissue was debrided away.
Hemostasis was obtained with electrocautery. The wound was
irrigated and then packed with some damp Kerlix. Plans were made to
look at the wound again tomorrow in the operating room and debride
away any other marginal tissue.
Pathology Report Later Indicated: Granulation tissue, inflammation,
and necrotic tissue.
Needed ICD 10, CPT, HCPCS
Procedure-Wide wound exploration; excision of necrotic skin and subcutaneous tissue- CPT 11004
Dx- Abdominal wound infection - ICD S31.609S
Dx -S/P C section infection - O86.0- ICD
Gary I. Sanchez, M.D. PREOPERATIVE DIAGNOSIS: Necrotizing wound infection, one week status post Cesarean section. POSTOPERATIVE...
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