Question

PREOPERATIVE DIAGNOSIS: Large right subdural hematoma.

POSTOPERATIVE DIAGNOSIS: Large right subdural hematoma.

PROCEDURE PERFORMED: Right craniotomy with evacuation of subdural hematoma.

HISTORY: This 58-year-old patient was transferred from an outside hospital after she was found unresponsive. She was on Coumadin, and she was found to have a large right-sided subdural hematoma with significant midline shift. On exam, she is noted to have, anisocoria and large right pupil, decerebrating, to pain. The patient had received FFP as well as factor VII and emergently rushed to the operating room.

PROCEDURE: The patient was brought into the general operating theater. Following the induction of general anesthesia, the patient was supine. The scalp was clipped, prepped and draped. We made a hairline incision frontal temporal parietal, reflecting it and incised down through the temporalis muscle. Fascia reflected with the skin flap. Bone flap was elevated without dural violation, tacked up to the bone edges with 4-0 Nurolon. As the dura was tacked up, the dura was opened. We encountered a very large subdural membrane. We circumferentially evacuated it. We did find a cortical arterial bleeder. Once it started bleeding, we removed the clot. This was coagulated, and the bleeding was stopped. We copiously irrigated, circumferentially inspecting the edges to make sure there was no venous bleeding. All seemed dry. We next reapproximated the dura. We did place a red rubber catheter in the subdural space. The dura was approximated with 4-0 Nurolon. Bone was placed back in place. Temporalis muscle and fascia were approximated with 2-0 Vicryl, the galea with inverted interrupted 2-0 Vicryl and the skin with staples.

Following this procedure, all instrument, sponge, needle and padding counts were correct.

What is the root operation/term for this procedure?

What is the ICD-10-PCS code assigned?

Answer 1

ROOT OPERATION :

Extirpation ( Complete excision or surgical removal of body part) .

ICD -10 PCS CODE :

00C40ZZ