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Incision and drainage, leg or ankle; deep abscess or hematoma

CPT4 code

Name of the Procedure:

Incision and Drainage, Leg or Ankle; Deep Abscess or Hematoma

Summary

Incision and drainage is a surgical procedure performed to treat a severe infection (abscess) or accumulation of blood (hematoma) deep in the leg or ankle. The surgeon makes an incision to drain the infected fluid or blood, relieving pressure and promoting healing.

Purpose

This procedure aims to treat deep abscesses or hematomas that may cause severe pain, swelling, and risk of spreading infection. The goal is to remove the accumulated fluid, alleviate symptoms, and prevent further complications.

Indications

  • Symptoms of a deep abscess or hematoma such as severe pain, swelling, redness, and warmth.
  • Signs of infection like fever and increased white blood cell count.
  • Failure of conservative treatments (e.g., antibiotics, rest, and ice).

Preparation

  • Patients may need to fast for a few hours before the procedure.
  • The doctor may instruct you to stop certain medications, such as blood thinners.
  • Pre-procedure assessments such as blood tests or imaging (e.g., MRI or ultrasound) may be required to locate the abscess or hematoma.

Procedure Description

  1. The patient is positioned to allow access to the affected area.
  2. Local anesthesia or sedation is administered to minimize discomfort.
  3. The surgeon makes an incision over the site of the abscess or hematoma.
  4. Pus or blood is drained using surgical instruments.
  5. The area is cleaned thoroughly to remove all infected material.
  6. In some cases, a drainage tube may be inserted to allow further drainage.
  7. The incision is closed with sutures or left open to heal naturally, depending on the situation.

Duration

The procedure typically takes 30 minutes to an hour, depending on the severity and location of the abscess or hematoma.

Setting

The incision and drainage procedure is generally performed in a hospital operating room or an outpatient surgical center.

Personnel

  • Surgeon
  • Surgical Nurse
  • Anesthesiologist (if general anesthesia or significant sedation is needed)

Risks and Complications

  • Common risks: bleeding, infection at the incision site, scarring.
  • Rare risks: deep vein thrombosis (DVT), damage to surrounding tissues, recurrence of abscess or hematoma.

Benefits

  • Immediate relief from pain and swelling.
  • Reduced risk of spreading infection.
  • Promotes quicker healing and return to normal activities.

Recovery

  • Follow post-procedure wound care instructions, such as keeping the area clean and dry.
  • Pain management with prescribed medications.
  • Avoid strenuous activities until cleared by your doctor, usually within 1-2 weeks.
  • Regular follow-up appointments to monitor healing and prevent complications.

Alternatives

  • Antibiotic therapy (for early-stage infections).
  • Aspiration with a needle (less effective for deep abscesses or large hematomas).
  • Observation and conservative management for minor collections, though this may carry a risk of progression.

Patient Experience

Patients may experience discomfort during recovery, which can be managed with pain relief medications. Minor soreness and swelling at the incision site are common. Follow-up care is crucial to ensure proper healing and prevent recurrence or further infection.

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