This is a very pleasant 28-year-old white female with previous placement of ventriculoperitoneal shunt for hydrocephalus who developed headaches over last 2-3 days. Imaging studies revealed a shunt malfunction with distal catheter breakage in the neck. After discussion with the family was decided proceed with surgical intervention consisting of a revision of distal ventriculoperitoneal shunt. The family was notified of the risks which included but were not limited to: Myocardial infarction, DVT and primary embolus, stroke, pneumonia, severe allergic reaction medications given during surgery, wound infection, wound hematoma, injury to the lungs are abdominal contents, and shunt malfunction requiring further revisions. Patient's family voiced understanding wished to proceed with surgery.
Patient was brought to the operating room. After general endotracheal anesthesia, she was placed in a supine position with her head on a donut type anesthesia pillow and head was rotated approximately 75 degrees to the left. The arms were brought down sides and all pressure points well padded including the ulnar nerves bilaterally. The left side of the scalp behind the ear the left neck, the left abdomen and chest were prepped and draped in a sterile fashion. Then after injection of approximately 3 cc of 0.25% Marcaine with epinephrine subcutaneously over the previous scalp incision, a linear incision was made with a 10 blade knife over the previous incision which was extended inferiorly in order to visualize the shunt. Electrocautery was used to bring the incision down to the shunt itself. Cerebellar retractor was used to retract soft tissues. A pickup was used to pull on the distal part of the ventricular peritoneal shunt which easily was removed and clearly showed a fracture of the catheter. The distal catheter was then removed. This was then connected to a antibiotic impregnated shunt with a 0 silk suture. Neck is incision was made over the previous incision at the midline of the abdomen opal of the navel. This was done with a 10 blade knife and the wound was brought down to the catheter using electrocautery. The distal catheter was then removed in its entirety. Next a tunneler was tunneled from the scalp incision to the abdomen and 1 pass. The catheter was then placed through the tunneler from the scalp to the abdomen prior to the tunneler being removed. The scalp wound was then copiously irrigated using orthopedic irrigation and closed using interrupted 2 Vicryl sutures to reapproximate the galea and a continuous 3 0 nylon sutures was used to reapproximate the skin. Attention was then given to the abdominal incision. The old track was investigated but showed too much scar tissue and decision was made to create a new entrance to the abdomen lateral to the previous site of on the left. Electrocautery was used to go down to the external abdominal fascia. This was divided using electrocautery. The external abdominal muscles were then divided using hemostats and the internal abdominal fascia was lifted using hemostats. A scissors was used to cut into the external abdominal fascia and peritoneum and a 4. Penfield was able to be placed at all directions in the abdomen cavity. The distal catheter in which dripping of CSF could be clearly seen was placed into the peritoneum and secured using a 2 0 Vicryl suture pursestring stitch. The external abdominal fascia was then closed using interrupted 2 Vicryl sutures as well as the subcutaneous tissues closed using interrupted 2 Vicryl sutures. This was done after copiously irrigating the wound. The skin was then closed using continuous 3 0 nylon suture. Sponge and needle counts were correct at the end the case. Estimated blood loss was less than 50 cc. Estimated crystalloid: Please see Anesthesia report. Patient remained in stable fashion throughout the case.
I coded removal of the distal shunt but how would you code the rest of the procedure?thank you for any help.Pat