Surgeon(s): ***
Assistant Surgeon(s): ***
Preoperative Diagnosis: ***
Postoperative Diagnosis: Same
Procedure(s): ***
Anesthesia: General
Implants: None
Specimen:***
Drains: None
Fluids: See anesthesia record
EBL: Minimal
Complications: None
Counts: Correct x2
Indications: ***
Findings: As expected
Procedure in Detail:
The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail. The patient was transferred to the operating room by the anesthesia team. The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures. A time-out was performed and the procedure began.
A carbon dioxide (CO2) laser with appropriate settings was employed for the ablation procedure, meticulously directed onto the lesion to ensure precise tissue removal. Utilizing a defocused mode helped minimize thermal damage to adjacent tissues while achieving effective hemostasis with minimal bleeding. Careful attention was paid to avoid unnecessary trauma to surrounding healthy tissues. Upon completion of lesion ablation, the area underwent thorough irrigation with sterile saline solution to eliminate any debris or residual tissue. Subsequently, hemostasis was reconfirmed, and the surgical site meticulously examined for any signs of incomplete ablation or bleeding.
The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.
Diagnosis Codes
Procedure Codes