AUDIT REPORT T5 $\times$ 30 Cm from the Right Thigh to the Right Lower

question 3

Essay

AUDIT REPORT T5.1 OPERATIVE REPORT, MUSCLE FLAP

PREOPERATIVE DIAGNOSIS: Right lower extremity open wound
POSTOPERATIVE DIAGNOSIS: Open wound, right lower extremity, with exposed tibia and exposed plate
PROCEDURES PERFORMED:
1. Soleus muscle flap.
2. Split-thickness skin graft 3.0 $\times$ 3.0 cm from the right thigh to the right lower extremity.
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: 60 cc
DRAINS: 1 no. 1 Jackson-Pratt
SURGICAL FINDINGS: There was an open wound extending from the lower third of the tibia up into the middle third of the right leg with an exposed plate, but tissue loss of the lower third of the right leg was evident.
PROCEDURE: An incision was made 3.0 cm medial to the tibial border. I developed a bilobed flap and identified the separation of the soleus muscle and the gastrocnemius medial head following incision of the deep fascia. The soleus muscle was freed distally as far as possible and then cut distally at the Achilles tendon insertion. The bilobed flap was formed covering the area of soft-tissue loss by using bolsters that were tied in place with 0 Prolene. With the open area covered, I then closed the remainder of the area, closing the donor area also with 0 Prolene. I put Nitro paste along the edges where there was some skin blanching and put a no. 1 Jackson-Pratt drain in the distal end of the wound, bringing it out through a separate stab wound incision. A spit-thickness skin graft about 3.0  3.0 cm was taken from the right thigh, meshed with a mesher, and applied to the defect with 2-0 Prolene, sutures, and staples. We dressed the wound with Xeroform, Kerlix fluffs, Kerlix roll, Kling, and a Sof-Rol, and then the orthopedic technician applied a cast. The donor site was dressed with scarlet red and an ABD pad. The patient tolerated the procedure well and left the area in good condition.
T5.1:
SERVICE CODE(S): 15738, 12032-51, 15100-RT__________________________
ICD-10-CM DX CODE(S): S81.809,Y93.9________________________________
INCORRECT/MISSING CODE(S): _____________________________________

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