PREOPERATIVE DIAGNOSIS: Ventilator dependency, pneumonia due to aspiration of
gastric secretions.
PROCEDURE PERFORMED: Tracheostomy.
DESCRIPTION OF PROCEDURE: After consent was obtained, the patient was taken to the
operating room and placed on the operating room table in the supine position. After an
adequate level of general endotracheal anesthesia was obtained, the patient was positioned for
tracheostomy. The patient's neck was prepped with Betadine and then draped in a sterile
manner. A curvilinear incision was marked approximately a fingerbreadth above the sternal
notch in the area just below the cricoid cartilage. This area was then infiltrated with 1%
Xylocaine with 1:100,000 units of epinephrine. After several minutes, sharp dissection was
carried down through the skin and subcutaneous tissue. The subcutaneous fat was removed
down to the strap muscles. Strap muscles were divided in the midline and retracted laterally.
The cricoid cartilage was then identified. The thyroid gland was divided in the midline with
the Bovie, and then the two lobes were retracted laterally, exposing the anterior wall of the
trachea. The space between the second and third tracheal rings was then identified. This was
infiltrated with local solution. A cut was then made through the anterior wall. The
endotracheal tube was then advanced superiorly. An inferior cut into the third tracheal ring
was then done to make a flap. This was secured to the skin with 4-0 Vicryl suture. A no. 6
Shiley cuffed tracheostomy tube was then placed and secured to the skin with ties as well as
the tracheostomy strap. The patient tolerated the procedure well and was taken to the critical
care unit in stable condition. Report the procedure(s) and diagnosis(es).
Choose the correct codes;
A. 94002, 60220, 31600-51, J69.8
B. 31500, 31600-51, J69.8
C. 31600, J69.0

D. 94002, 31502-51, 31600-51, J96.90, J69.00