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WESTWARD HOSPITAL 591 Chester Road Masters, FL 33955 OPERATIVE REPORT PATIENT: KENSINGTON, LOUIS DATE OF ADMISSION: 10/07/24 DATE OF DISCHARGE: 10/09/24 ADMITTING DIAGNOSIS: Chronic anal fissure and anal stenosis. DISCHARGE DIAGNOSIS: Chronic anal fissure and anal stenosis. OPERATIONS: V-Y anoplasty. Lateral internal sphincterotomy with fissurectomy. Flexible sigmoidoscopy. ESTIMATED BLOOD LOSS: 30 mL. SPECIMENS: No specimens. DRAINS: A 0.25-inch Penrose to the flap. COMPLICATIONS: None. DESCRIPTION OF OPERATION: After informed consent was obtained, the patient was taken to the OR. He was placed in the prone jackknife position and IV sedation was given by the anesthesiologist. The buttocks were taped laterally, exposing the perianal area. I began with the lubricated scope. The videoscope was inserted into the rectum and advanced through the colon to about 40 cm. At 40 cm, there was some angulation and some looping of the scope, and I elected not to proceed beyond this point. I then began to slowly withdraw the scope, carefully inspecting the lumen. The prep was adequate up to this point. I withdrew the scope. I noted no tumors or polyps. There was no evidence of colitis or proctitis and no diverticular disease was noted. I then desufflated the colon and rectum and removed the scope. The perianal area was then prepped with Betadine and draped in the usual fashion. I then used a solution of 0.5% Marcaine with epinephrine and injected about 30 mL perianally as well as intramuscularly to achieve some relaxation of the sphincter muscles. After adequate analgesia was obtained, the small Ferguson retractor was inserted and the anal canal was inspected. The anterior fissure was very chronic appearing and measured about 1 × 0.5 cm in size. The anal canal was rather small and there seemed to be spasm of the distal edge of the internal sphincter muscle. I then inserted the Buie retractor and opened it to expose the right lateral anal canal. An incision was made over the anoderm in the right lateral position and then I dissected down to the distal edge of the internal sphincter muscle, which was easily palpable as a tight band. I used a hemostat to dissect underneath it and elevated and divided it for a length of less than 1 cm. This did achieve relaxation of the sphincter muscle. Then at this point, I was able to remove the Buie retractor and inserted the Chelsea-Eaton retractor. There was a definite release of the spasm of the sphincter muscle. However, there was also now obvious evidence of stenosis of the anal canal and there was no way to bring the mucosal edges together to cover the sphincterotomy wound without putting tension on the anal canal. Because of this, I did elect to go ahead with the anoplasty. I used a marking pen to outline a house-shaped flap on the perianal skin in the right lateral position. I then anesthetized this area. I used a #15 blade scalpel to incise the skin edges. I then mobilized the flap by dissecting laterally to give the flap a very broad base. With the lateral dissection, I was then able to mobilize the flap down into the anal canal to cover up the lateral internal sphincterotomy wound. The area was irrigated. Then the flap was sewed into place using interrupted sutures, using combination of #3-0 Vicryl and #4-0 Vicryl sutures, using the #3-0 Vicryl primarily on the tension points of the flap. Once the proximal edge of the flap was sewed to the dentate line, I then came up the anterior and posterior sides of the flap, suturing again in an interrupted fashion to the cut mucosal edges. I then used a scalpel to make a small incision in the right posterior position about 1 centimeter or 2 away from the flap and then used the stab incision to bring a 0.25-inch Penrose through the skin and positioned it underneath the flap. It was sutured to the skin with a single #3-0 Vicryl suture. The excess drain was then cut away, leaving about 2 or 3 cm protruding and the remainder positioned underneath the flap. I then used #2-0 Vicryl and a mattress suture to perform the long portion of the Y of the flap. This was done on the distal edge of the incision, bringing the two skin edges together with two of these mattress sutures to form the Y. At this point, I now just had the remainder of the bottom of the Y portion of the flap to close and this was done again using a combination of interrupted #3-0 and #4-0 Vicryl sutures. At this point, I had good hemostasis throughout the flap and the flap appeared to be viable. There was no tension on it. There was a good color with no blanching noted. I then directed my attention back toward the anal fissure in the anterior position. The small anterior tag was excised. That was a small hypertrophied anal papilla. I then mobilized the mucosal side of the fissure, elevating the mucosa, and a very small amount of muscle as well and then used a #4-0 Vicryl suture to bring this mucosal edge about halfway up the fissure to partially cover it and facilitate the healing process. There was a small amount of bleeding that was controlled with the #3-0 Vicryl figure-of-eight suture. At this point, I had good release of the anal stenosis and good hemostasis throughout. On further examination, there was a very small posterior anal fissure, which was simply coagulated with the electrocautery. At this point, the retractor was removed. A roll of Gelfoam was placed in the anal canal and then a fluffy gauze dressing was placed over the Gelfoam. The patient was then returned to the supine position and taken to the recovery area in stable condition. Phillip Carlsson, MD Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Determine the most accurate ICD-10-PCS code(s). The number of spaces provided does not indicate the number of codes required to accurately report this encounter.

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