Location: Outpatient Hospital OPERATIVE REPORT

question 4

Short Answer

Location: Outpatient Hospital
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Septal deviation.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Septoplasty.
OPERATIVE NOTE: The patient was admitted through the same-day surgery department and taken to the operating room and was administered general anesthetic by intravenous injection and was intubated endotracheally. His nose was decongested with 4 cc of 4% cocaine solution on nasal pledgets. A small amount of Afrin was also used. The patient was draped in the usual fashion. The packing was then removed and the left septum was injected with 1% lidocaine with epinephrine. A left hemitransfixion incision was created with a Beaver blade and a mucoperichondrial flap was elevated on this side; this was extended posteriorly over the perpendicular plate of ethmoid and vomer, extended inferiorly over a septal spur. We then separated the bony and cartilaginous septum to elevate it on the opposite side. We elevated on either side of the maxillary crest. A 4-mm osteotome was used to remove this. A portion of inferior cartilage was also removed. Once this was completed we laid the mucosa back into position and the septum was nicely reduced. We closed the caudal hemitransfixion incision with interrupted 3-0 Chromic suture. The septum was closed with 4-0 plain gut suture. Doyle splints were then placed on either side of the nose. The patient was then allowed to recover from the anesthetic and taken to the postanesthesia care unit in stable condition. There were no complications during this procedure.
CPT Code: ____________________

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