Any help would be greatly appreciated!
Kelly C, CPC
Indication for Surgery
left breast cancer, positive skin margin
excision left breast skin
drainage of hematoma
Estimated Blood Loss
The PSI-15 for accidental puncture or laceration is: none
The frozen section: none
Important intraoperative findings are as follows: old blood evacuated, more skin removed from the lateral skin flaps and reclosed
DISPOSITION OF PATIENT IS: pacu
lateral skin new stitch on margin
inferior/lateral skin new stitch on margin
After informed consent was obtained patient was brought to operating room and given preoperative antibiotics and IV sedation with anesthesia. I accessed the right chest port. I removed the steris and bilateral JP drains. The left breast and axilla was prepped and draped with Chloraprep in the usual fashion and allowed the dry 3 minutes before draping. I removed the lateral skin ellipse 8 x 3 cm portion, marked. Then took another 2 cm margin on the inferior skin flap. Good hemostasis was insured and the area washed out copiously. I then placed 10F JP drain into the space from the axilla and sutured it in with 3-0 nylon. The skin was reapproximated with deep 2-0 vicryl and 4-0 monocryl sutures. Dermabond applied, sterile dressings placed, and patient was taken to recovery room in stable condition.