Miko24
Guru
Specimens:
1. Cystoprostatectomy specimen
2. Bilateral ureteral margins for frozen section
3. Right and left pelvic lymph nodes
A 5mm incision is made in the LUQ using a scalpel. A 5mm optical trocar is passed through the skin and into the abdomen underdirect visualization. I was able to visualize some adhesion midline in the pelvis and on the patient's right side.
The abdomen was insufflated to 15 cm of water pressure. Above the umbilicus an 8 mm incision was made with the Bovie. The camera port was inserted into the abdomen. On the patient's left side a 5 mm, an 8 mm, and a 10 mm port were all placed after incising the skin with the Bovie. All the ports were placed with the camera in the abdomen to ensure no injury to the underlying abdominal contents. A grasper and cold scissors was placed through these ports. I used these to perform a lysis of adhesions in the midline and on the right side. These were all omental adhesions. Eventually the adhesions were dropped. I was then able to place a 12mm and an 8mm port on the patient's left side. Similarly, the skin was incised with the bovie and the ports were placed under direct visualization.
The robot was brought in and docked to the ports. The robotic instruments inserted under direct visualization with the camera. The sigmoid colon was mobilized sharply. An incision was made in the White Line of Toldt to mobilize the left colon partially. The left ureter was dissected in the retroperitoneum at the level of the iliac vessels. The ureter was sharply dissected distally to the level of the bladder. The superior vesicle artery was encountered and divided using the vessel sealer device. The ureter was dissected down to the bladder. The ureter was then doubly clipped with Wek clips. The ureter was divided and a margin was sent for frozen section. The ureter was then mobilized cephalad from the iliac vessels as much as possible.
Attention turned to the right side of the pelvis. The terminal ileum was visualized. The right colon was mobilized sharply by incising the White Line. Small bowel was retracted out of the retroperitoneum. The retroperitoneum was incised overlying the iliac vessels. The ureter was identified and sharply dissected. The ureter was dissected down to the bladder similarly to the left side. The superior vesical artery was divided using the vessel sealer. The ureter was doubly clipped at the level of the bladder. The ureter was divided and a margin was obtained and sent to pathology.
The posterior peritoneum was incised in the space of Douglas. We placed a sponge stick in the vagina externally and used this to visualize the vaginal cuff.
On the left side, the bladder was retracted anteriorly. The bladder pedicles were identified and divided using the vessel sealer. I was careful to stay posterior to the ureter. Eventually the pedicles were divided down to the level of the endopelvic fascia. I then opened the anterior peritoneum lateral to the obliterated umbilical artery on the left side. The peritoneal incision was carried down lateral to the bladder. The vas deferens was divided using the vessel sealer device.
The bladder pedicles were divided on the right side in a similar fashion using the vessel sealer device. I created a plane between the bladder and vagina. This plane was difficult to create -- likely related to scar tissue from previous hysterectomy. Eventually I opened the vagina anteriorly and visualized the sponge stick.
I opened the endopelvic fascia on both sides using sharp dissection. The endopelvic fascia was opened as far towards the bladder apex as possible.
I then used the 30 degree lens upward to visualize the Urachus. This was dissected just caudally from the umbilicus and divided using the vessel sealer device. I then proceeded to dissect the anterior peritoneum off of the anterior abdominal wall and enter the space of Retzius. Eventually the bladder was mobilized and the pubic bone was encountered. The anterior urethra was then visualized.
The bladder neck was identified and opened anteriorly. The Foley catheter was visualized and used as traction on the bladder. The foley was pulled through the incision and a Wek clip was placed. The foley was cut downstream from the Wek clip. The posterior bladder neck was divided. The cystoprostatectomy specimen was freed at this point. The bladder neck was sutured shut with a 2-O vlock suture. The specimen was pushed into the upper abdomen. The pedicles were examined and there appeared to be excellent hemostasis.
The vaginal cuff was closed with a running 2-O Vlock suture. There appeared to be excellent hemostasis in the pelvis. A 16 fr foley catheter was placed through the urethra and into the pelvis to serve as a pelvic drain.
A pelvic lymph node dissection was performed on the left side. The internal iliac vein was identified. The node packet was dissected off the medial aspect of the vein and then dissected back to the pelvic sidewall. The node packet was dissected distally to Cooper's ligament. The vessel sealer device was used to divide the node packet distally. Inferiorly, the obturator nerve is identified. The node packet is dissected proximally off the obturator nerve. The packet is dissected back to the bifurcation of the internal and external iliacs. The packet is divided at this point using the vessel sealer. The lymph node packet is then mobilized off of the external iliac artery. This is mobilized back to the bifurcation of the external/internal iliac artery. The packet is divided using the vessel sealer device. The packet is then removed with a spoon tip grasper and labeled for pathology. The obturator nerve is inspected and free of any injury. The same procedure is performed on the patient's right side.
The sigmoid colon is then visualized and retracted anteriorly. On the patient's right side, gentle dissection underneath the sigmoid mesentary is performed below the aortic bifurcation overlying the sacral promontory. I am able to pass the prograsp forceps through the mesentery to the left side of the sigmoid colon. The left ureteral tagging suture is placed within the prograsp and the prograsp is gently pulled through under the sigmoid to reposition the left ureter into the right retroperitoneum.
Dr B. then takes over the operation at this point to perform the creation of the ileal conduit from the terminal ileum. He divided the bowel approximately 15cm from the ileo-cecal valve. A conduit is created and placed inferiorly. He then performed the bowel anastomosis.
The abdominal end of the conduit is opened with a scissors. The conduit is irrigated copiously with normal saline. A Cadier grasper is inserted through the conduit to the butt end on the left side. An incision is made through the bowel onto the tips of the grasper. A 7fr x 90cm single J stent is passed to the grasper. The grasper is then pulled back out through the distal end of the conduit.
The left ureter is freshened and spatulated. Two 3-O stratafix sutures are placed on each side of the apex of the ureter and to the corresponding location on the conduit. A wire is placed through the stent. The stent is then passed into the left ureter approximately 25cm. The wire is removed. The stratafix sutures are then used to finish the anastomosis. The right sided anastomosis and stent placement are performed similarly. The stents are secured to the distal conduit using interrupted 3-O chromic sutures.
A 15fr blake drain is brought in through the lateral 5mm port on the patient's left side. The drain is positioned in the pelvis and under the conduit anastomosis. There is excellent hemostasis. The robotic instruments are removed and the robot is undocked.
A low midline incision is marked for about 4cm. The skin is incised with a scalpel and taken down to the fascia using electrocautery. The peritoneum is opened sharply and there is no bowel in the vicinity as the pneumoperitoneum was still intact. The abdomen was then deflated. The cystoprostatectomy specimen is removed intact.
A Rosebud type stoma is created. The skin is incised overlying the stomal marking lateral to midline on the right side. The fat is incised down to the fascia using the bovie. The fascia is cleared and a cruciate incision is made in the fascia. The posterior fascia and peritoneum are incised and opened. Two finger breadths can be passed through the rectus sheath and the incision. A Babcock clamp is then used to pull the conduit up through the opening. The conduit is sutured to the fascia in four quadrants using 2-O vicryl sutures. Four 3-O vicryl sutures are then used to invert the stoma. The intervening stomal mucosa is sutured to the skin with interrupted 3-O vicryl sutures. The stoma is matured at this point.
The previously placed Blake drain is sutured to the skin with a 2-O nylon suture. The midline incision is closed with a running O pds loop suture. The incision is irrigated with saline. The skin incisions are closed with staples. The urostomy appliance is placed.
We check the vagina to make sure the previous sponge stick had been removed. There was some bloody drainage noted and I was able to palpate the foley catheter balloon. Further inspection revealed that the vaginal cuff had not been completely closed. The patient was then placed in the trendelenburg position. Handheld vaginal retractors were utilized by my assistant. I grasped the the edges of the vaginal cuff with Allis clamps. An O PDS running suture was used to close the open portion of the vaginal cuff on the patient's right side. I was able to visualize the edges of the cuff well for closure.
I will address the cystoprostatectomy and vans deferens in female pt.
51999 benchmarked to 51590?
unsure of the vaginal cuff closure - 57200 or 58999 or is it part of the procedure
Thank you!!!
1. Cystoprostatectomy specimen
2. Bilateral ureteral margins for frozen section
3. Right and left pelvic lymph nodes
A 5mm incision is made in the LUQ using a scalpel. A 5mm optical trocar is passed through the skin and into the abdomen underdirect visualization. I was able to visualize some adhesion midline in the pelvis and on the patient's right side.
The abdomen was insufflated to 15 cm of water pressure. Above the umbilicus an 8 mm incision was made with the Bovie. The camera port was inserted into the abdomen. On the patient's left side a 5 mm, an 8 mm, and a 10 mm port were all placed after incising the skin with the Bovie. All the ports were placed with the camera in the abdomen to ensure no injury to the underlying abdominal contents. A grasper and cold scissors was placed through these ports. I used these to perform a lysis of adhesions in the midline and on the right side. These were all omental adhesions. Eventually the adhesions were dropped. I was then able to place a 12mm and an 8mm port on the patient's left side. Similarly, the skin was incised with the bovie and the ports were placed under direct visualization.
The robot was brought in and docked to the ports. The robotic instruments inserted under direct visualization with the camera. The sigmoid colon was mobilized sharply. An incision was made in the White Line of Toldt to mobilize the left colon partially. The left ureter was dissected in the retroperitoneum at the level of the iliac vessels. The ureter was sharply dissected distally to the level of the bladder. The superior vesicle artery was encountered and divided using the vessel sealer device. The ureter was dissected down to the bladder. The ureter was then doubly clipped with Wek clips. The ureter was divided and a margin was sent for frozen section. The ureter was then mobilized cephalad from the iliac vessels as much as possible.
Attention turned to the right side of the pelvis. The terminal ileum was visualized. The right colon was mobilized sharply by incising the White Line. Small bowel was retracted out of the retroperitoneum. The retroperitoneum was incised overlying the iliac vessels. The ureter was identified and sharply dissected. The ureter was dissected down to the bladder similarly to the left side. The superior vesical artery was divided using the vessel sealer. The ureter was doubly clipped at the level of the bladder. The ureter was divided and a margin was obtained and sent to pathology.
The posterior peritoneum was incised in the space of Douglas. We placed a sponge stick in the vagina externally and used this to visualize the vaginal cuff.
On the left side, the bladder was retracted anteriorly. The bladder pedicles were identified and divided using the vessel sealer. I was careful to stay posterior to the ureter. Eventually the pedicles were divided down to the level of the endopelvic fascia. I then opened the anterior peritoneum lateral to the obliterated umbilical artery on the left side. The peritoneal incision was carried down lateral to the bladder. The vas deferens was divided using the vessel sealer device.
The bladder pedicles were divided on the right side in a similar fashion using the vessel sealer device. I created a plane between the bladder and vagina. This plane was difficult to create -- likely related to scar tissue from previous hysterectomy. Eventually I opened the vagina anteriorly and visualized the sponge stick.
I opened the endopelvic fascia on both sides using sharp dissection. The endopelvic fascia was opened as far towards the bladder apex as possible.
I then used the 30 degree lens upward to visualize the Urachus. This was dissected just caudally from the umbilicus and divided using the vessel sealer device. I then proceeded to dissect the anterior peritoneum off of the anterior abdominal wall and enter the space of Retzius. Eventually the bladder was mobilized and the pubic bone was encountered. The anterior urethra was then visualized.
The bladder neck was identified and opened anteriorly. The Foley catheter was visualized and used as traction on the bladder. The foley was pulled through the incision and a Wek clip was placed. The foley was cut downstream from the Wek clip. The posterior bladder neck was divided. The cystoprostatectomy specimen was freed at this point. The bladder neck was sutured shut with a 2-O vlock suture. The specimen was pushed into the upper abdomen. The pedicles were examined and there appeared to be excellent hemostasis.
The vaginal cuff was closed with a running 2-O Vlock suture. There appeared to be excellent hemostasis in the pelvis. A 16 fr foley catheter was placed through the urethra and into the pelvis to serve as a pelvic drain.
A pelvic lymph node dissection was performed on the left side. The internal iliac vein was identified. The node packet was dissected off the medial aspect of the vein and then dissected back to the pelvic sidewall. The node packet was dissected distally to Cooper's ligament. The vessel sealer device was used to divide the node packet distally. Inferiorly, the obturator nerve is identified. The node packet is dissected proximally off the obturator nerve. The packet is dissected back to the bifurcation of the internal and external iliacs. The packet is divided at this point using the vessel sealer. The lymph node packet is then mobilized off of the external iliac artery. This is mobilized back to the bifurcation of the external/internal iliac artery. The packet is divided using the vessel sealer device. The packet is then removed with a spoon tip grasper and labeled for pathology. The obturator nerve is inspected and free of any injury. The same procedure is performed on the patient's right side.
The sigmoid colon is then visualized and retracted anteriorly. On the patient's right side, gentle dissection underneath the sigmoid mesentary is performed below the aortic bifurcation overlying the sacral promontory. I am able to pass the prograsp forceps through the mesentery to the left side of the sigmoid colon. The left ureteral tagging suture is placed within the prograsp and the prograsp is gently pulled through under the sigmoid to reposition the left ureter into the right retroperitoneum.
Dr B. then takes over the operation at this point to perform the creation of the ileal conduit from the terminal ileum. He divided the bowel approximately 15cm from the ileo-cecal valve. A conduit is created and placed inferiorly. He then performed the bowel anastomosis.
The abdominal end of the conduit is opened with a scissors. The conduit is irrigated copiously with normal saline. A Cadier grasper is inserted through the conduit to the butt end on the left side. An incision is made through the bowel onto the tips of the grasper. A 7fr x 90cm single J stent is passed to the grasper. The grasper is then pulled back out through the distal end of the conduit.
The left ureter is freshened and spatulated. Two 3-O stratafix sutures are placed on each side of the apex of the ureter and to the corresponding location on the conduit. A wire is placed through the stent. The stent is then passed into the left ureter approximately 25cm. The wire is removed. The stratafix sutures are then used to finish the anastomosis. The right sided anastomosis and stent placement are performed similarly. The stents are secured to the distal conduit using interrupted 3-O chromic sutures.
A 15fr blake drain is brought in through the lateral 5mm port on the patient's left side. The drain is positioned in the pelvis and under the conduit anastomosis. There is excellent hemostasis. The robotic instruments are removed and the robot is undocked.
A low midline incision is marked for about 4cm. The skin is incised with a scalpel and taken down to the fascia using electrocautery. The peritoneum is opened sharply and there is no bowel in the vicinity as the pneumoperitoneum was still intact. The abdomen was then deflated. The cystoprostatectomy specimen is removed intact.
A Rosebud type stoma is created. The skin is incised overlying the stomal marking lateral to midline on the right side. The fat is incised down to the fascia using the bovie. The fascia is cleared and a cruciate incision is made in the fascia. The posterior fascia and peritoneum are incised and opened. Two finger breadths can be passed through the rectus sheath and the incision. A Babcock clamp is then used to pull the conduit up through the opening. The conduit is sutured to the fascia in four quadrants using 2-O vicryl sutures. Four 3-O vicryl sutures are then used to invert the stoma. The intervening stomal mucosa is sutured to the skin with interrupted 3-O vicryl sutures. The stoma is matured at this point.
The previously placed Blake drain is sutured to the skin with a 2-O nylon suture. The midline incision is closed with a running O pds loop suture. The incision is irrigated with saline. The skin incisions are closed with staples. The urostomy appliance is placed.
We check the vagina to make sure the previous sponge stick had been removed. There was some bloody drainage noted and I was able to palpate the foley catheter balloon. Further inspection revealed that the vaginal cuff had not been completely closed. The patient was then placed in the trendelenburg position. Handheld vaginal retractors were utilized by my assistant. I grasped the the edges of the vaginal cuff with Allis clamps. An O PDS running suture was used to close the open portion of the vaginal cuff on the patient's right side. I was able to visualize the edges of the cuff well for closure.
I will address the cystoprostatectomy and vans deferens in female pt.
51999 benchmarked to 51590?
unsure of the vaginal cuff closure - 57200 or 58999 or is it part of the procedure
Thank you!!!