I'm stuck on this one and any help would be greatly appreciated. I'm torn between either 10140 or 49010.
After the abdomen was prepped and draped in the usual sterile fashion, a right-sided suprapubic transverse incision was made for distance of approximately 3 cm off of midline, and the skin and subcutaneous tissue were sharpened down to the level of the fascia. Hemostasis was accomplished using electrocautery. The fascia was divided longitudinally and the underlying rectus muscle was distracted to the posterior sheath, which was then dissected out clearly and through and into the pelvic hematoma and seroma, which was opened widely to approximately 2 cm in diameter, and aspirated approximately 800 mL of fluid which was sent for culture sensitivity and also for cytology as the digital exploration of the
cavity ensued a larger chunk of semisolid tissue was identified and this was
sent off as a separate histologic specimen for evaluation. The pelvic cavity
was then irrigated and aspirated thoroughly using saline and sterile water
until the digital inspection demonstrated largely resolved cavity and
collection and debris in the pelvis. A Jackson-Pratt 10 mm drain was placed
in depth of the pelvis and sutured at the skin level with a 3-0 nylon. The
skin was loosely approximated using 3-0 nylon as well. Sterile dressing was
then placed and wound terminally anesthetized using 0.5% Marcaine with
epinephrine. A sterile dressing was placed.
Thank you
After the abdomen was prepped and draped in the usual sterile fashion, a right-sided suprapubic transverse incision was made for distance of approximately 3 cm off of midline, and the skin and subcutaneous tissue were sharpened down to the level of the fascia. Hemostasis was accomplished using electrocautery. The fascia was divided longitudinally and the underlying rectus muscle was distracted to the posterior sheath, which was then dissected out clearly and through and into the pelvic hematoma and seroma, which was opened widely to approximately 2 cm in diameter, and aspirated approximately 800 mL of fluid which was sent for culture sensitivity and also for cytology as the digital exploration of the
cavity ensued a larger chunk of semisolid tissue was identified and this was
sent off as a separate histologic specimen for evaluation. The pelvic cavity
was then irrigated and aspirated thoroughly using saline and sterile water
until the digital inspection demonstrated largely resolved cavity and
collection and debris in the pelvis. A Jackson-Pratt 10 mm drain was placed
in depth of the pelvis and sutured at the skin level with a 3-0 nylon. The
skin was loosely approximated using 3-0 nylon as well. Sterile dressing was
then placed and wound terminally anesthetized using 0.5% Marcaine with
epinephrine. A sterile dressing was placed.
Thank you
I&D, Aspiration & Evacuation of Intraabdominal Pelvic Hematom
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