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Original Question
Operative Report, Osteoplastic Craniotomy The following craniotomy is for the purpose of removal of a subdural hematoma. LOCATION: Inpatient, Hospital PATIENT: Larry Colter ATTENDING PHYSICIAN: Timothy Pleasant, MD SURGEON: Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Acute subdural hematoma, left side POSTOPERATIVE DIAGNOSIS: Acute subdural hematoma, left side PROCEDURE PERFORMED: Osteoplastic craniotomy ANESTHESIA: General anesthesia PROCEDURE:Under general anesthesia, the left head was prepped and draped in the usual manner after having been placed in Mayfield pins. Hemoclips and Dandy clips were utilized on the scalp edges. Part of the temporalis muscle was taken down. Two burr holes and a circumferential flap were made. The bone was elevated. The dura was incised in an inverted U-shaped fashion. We saw acute clot; probably 45-50 cc of clot was irrigated from the frontal, temporal, and posterior parietal areas (indicates supratentorial; see Figure 12-2). Having cleaned it out, there was no free bleeder that I saw. I placed a piece of Gelfoam on the brain and then began closure of the dura with 3-0 Vicryl; this was done. A little patch was necessary; we used temporalis fascia. We tacked up the dura, replaced the bone flap, and utilized Wurzburg plates and burr hole cover. Having secured this, we then closed the scalp with 2-0 Vicryl on the galea with surgical staples on the skin, with a Hemovac drain having been applied prior to closure. SERVICE CODE(S): ICD-10-CM DX CODE(S):
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