The report below describes a patient undergoing excision of the left dorsalis pedis artery aneurysm. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed and to learn about the use of the unlisted procedure code for this cardiovascular procedure.nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. n
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nDATE OF OPERATION: 01/XX/2021nOPERATING SURGEON: S. G., M.D.nPREOPERATIVE DIAGNOSIS: Left dorsalis pedis artery aneurysm.nPOSTOPERATIVE DIAGNOSIS: Left dorsalis pedis artery aneurysm.nPROCEDURE PERFORMED: Excision of left DP artery aneurysm.nANESTHESIA: Monitored anesthesia care with local anesthetic.nASSISTANTS: None.nINDICATION: The patient is a 40-year-old male with a history of acute onset of left foot pain. Ultrasound demonstrated a pseudoaneurysm versus aneurysm of the dorsalis pedis artery. The patient did not have any blue toes but based on the symptoms of pain and the location, it was recommended he undergo excision. Risks, benefits, and alternatives were discussed with the patient. He consented to procedure.nnDESCRIPTION OF PROCEDURE: On the operative day, the patient was met in the preop holding area. All site verification consent forms were completed and placed in the chart. The patient was then taken to the OR, placed on table in supine position. After induction of general anesthetic, the patient was prepped and draped in usual sterile fashion. Final time-out was then performed by all in attendance to be correct patient, correct procedure, correct site, and the antibiotics had been administered. Using ultrasound, the anterior tibial and dorsalis pedis artery were mapped. Of note, right at the ankle, the dorsalis pedis branched into a medial and lateral branch. The lateral branch was the one that proceeded on to the aneurysmal region. This area again was marked on the skin. At this point, a sterile pulse ox was placed on the great toe and hooked up to the machine for continuous monitoring. An incision remained over the marked area after the area was anesthetized with lidocaine and Marcaine mix. This was carried down through soft tissue using electrocautery. The retinaculum was identified and divided and neurovascular bundle exposed. The dorsalis pedis just distal to the medial branch was vessel looped and a test clamp was performed. This resulted into no deficit of the waveform or pulse oximetry reading in the great toe. Additionally, he had excellent color and signal distal to this test ligation. At this point, I traced distally along the artery until the aneurysmal portion was identified. It was noted that there was no Doppler signal or flow within this vessel in this position. At this point, I then carried the incision down to more normal appearing vessel and then placed 2 clips. This was then removed and opened on the back table revealing some atheroma. At this point, the incision was irrigated. Hemostasis was assured. It was closed in multiple layers with Vicryl and a Monocryl suture. Sterile dressing was applied in addition to Steri-Strips. The patient tolerated the procedure well. No complications.nnESTIMATED BLOOD LOSS: 5 cc. TOTAL FLUIDS: 600 mL.nTOTAL LOCAL: 9 mL.nSPECIMEN: Left dorsalis pedis artery to pathology.