Burr hole with evacuation of hematoma

INDICATIONS FOR PROCEDURE: Subdural hematoma, chronic and acute, right parietal.

PROCEDURE PERFORMED: Bur hole evacuation of subdural hematoma with Jackson-Pratt drainage left in place.

PROCEDURE TIME & MAGNIFICATION: Approximately 1 hour; 4.5 magnification was used throughout.

CONSENT FOR PROCEDURE: The patient's family, sons, daughters and daughters-in-law were advised of the nature, necessity, complications, alternatives, technique, treatment, possibilities of death, hemorrhage, infection, paralysis, loss of sensation, worsening of present condition, bowel and/or bladder dysfunction, loss in vision, pain, suffering, and other, and still they request the same procedure be done on their behalf, after a conference over the above utilizing CT scans as well as fairly prolonged conference in the office.

DESCRIPTION OF THE PROCEDURE: The patient was taken down to the operating room, placed in the supine position, and there placed under general endotracheal anesthesia. He was turned over on the OR table, head canted gently to the left. The posterior occiput on the right side was shaved, prepped and draped in the usual sterile fashion. A skin incision was carried down through the skin and subcutaneous tissue and galea. Retractors were placed. The bur hole was done, dura was lysed and fluid escaped. Dura was very thick, cauterized back. There were loculated pockets beneath the dura and/or incision. These were broken up individually and various amounts of fluid were expurgated at each pocket being broken up. There was a fairly good space left anteriorly for the Jackson-Pratt drain, which was placed carefully. Irrigation continued through the same anteriorly. It was tunneled out inferiorly and posteriorly, and secured with suture, and placed under negative pressure to a grenade. The wound was closed with 1 layer of 0 interrupted Vicryl in galea, and the skin was brought together with staples.

Sponge and needle count was correct. Jackson-Pratt had been sutured in and the wound bandaged. The patient was taken to the recovery room.

codes: 
Code: 
61154
Code Type: 
CPT
Code: 
01.31
Code Type: 
ICD-9
Code: 
009400Z
Code Type: 
ICD-10