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Can I please have help for this operative report.
Which one is it; 55831 or 55899?
The patient had robotic assisted partial retro pubic prostatectomy, but the paramedian incision was done, 2-3 cm in size and partial prostate was removed at the end through that paramedian incision,after robotic port was removed.
Here is the copy of that report, thank you for your help.
A paramedian incision is made below the umbilicus on the right hand side
approximately 2 to 3 cm in size, carried through the skin, the
subcutaneous tissue, and the rectus abdominis fascia. The retropubic
space is entered first with a finger and then a balloon dilator, and the
peritoneal reflection is pulled off the anterior abdominal wall with the
use of finger dissection. Robotic ports are placed 10 cm to the right, 9
cm to the left, and 9 cm further to the left of the paramedian incision,
with a 12 mm Assistant's port placed on the right side as well. Each is
placed with an extra-long Kelly clamp and a one inch malleable retractor
under direct palpation and directed into the pelvis.
The robotic instrument is docked in place, and a cautery scissors is
placed in the right hand, and a Maryland bipolar dissector in the left
hand, and a ProGrasp retractor in the far left hand. The fat overlying
the prostate is removed with the bipolar Maryland and the cautery scissors and discarded. An inverted "T" incision is made through the prostate and
pseudocapsule until the adenoma is encountered. The pseudocapsule is
elevated off the underlying adenoma laterally on left and right sides, and
also the bladder neck is pulled off the adenoma until the bladder neck
mucosal fibers are seen, and the mucosa is divided. A tenaculum is used
in the far left hand, and the adenoma is elevated out of the prostatic
fossa. The junction between the pseudocapsule and the adenoma is
identified and separated freeing the adenoma up laterally posteriorly
until the apex is encountered. The posterior lip of the bladder neck
mucosa was divided with the scissors as is the mucosa of the apex where
the urethra is. The adenoma is then completely freed, placed in an Endo
Catch bag, and will be retrieved at the end of the case.
With the ProGrasp retractor back into the far left hand, the prostatic
fossa is cauterized with the coagulating electrocautery with the cautery
scissors, and two needle drivers used to place a figure-of-8 sutures at
the 4 o'clock and 8 o'clock positions where the vascular pedicles enter.
Then 2-0 sutures are used to evert bladder neck mucosa into the fossa
which meets up with the urethral mucosa. The bladder neck mucosa is
everted with 3-0 interrupted sutures circumferentially.
All needles are successfully retrieved from the abdomen. A 22-French,
three-way Foley catheter is inserted and inflated with 50 mL of sterile
water. The pseudocapsule is closed with two separate running sutures of 2-
0 Vicryl. At the conclusion, the Foley catheter is irrigated, and the
color of the irrigant return is light pink. The Foley catheter is left
continuous irrigation, and a 15-French Jackson-Pratt drain is passed
through the left-sided medial robotic port and left overlying the
capsulotomy.
All the instruments are removed. The robotic instrument is undocked, and
the ports are removed. The prostate is retrieved through the paramedian
incision with the previously placed Endo Catch bag and is sent to
pathology laboratory for evaluation. The paramedian incision is closed
with 0 Vicryl sutures both at the fascial and subcutaneous layers. All
port sites are copiously irrigated with antibiotic saline and closed with
Indermil skin glue. The Jackson-Pratt drain is secured with a 0 Vicryl
suture, and left to bulb drainage, and the Foley catheter is left to
continuous irrigation drainage. The patient is then reversed from anesthesia, brought to the recovery area in awake, alert, and in stable
condition having tolerated the procedure well.
Which one is it; 55831 or 55899?
The patient had robotic assisted partial retro pubic prostatectomy, but the paramedian incision was done, 2-3 cm in size and partial prostate was removed at the end through that paramedian incision,after robotic port was removed.
Here is the copy of that report, thank you for your help.
A paramedian incision is made below the umbilicus on the right hand side
approximately 2 to 3 cm in size, carried through the skin, the
subcutaneous tissue, and the rectus abdominis fascia. The retropubic
space is entered first with a finger and then a balloon dilator, and the
peritoneal reflection is pulled off the anterior abdominal wall with the
use of finger dissection. Robotic ports are placed 10 cm to the right, 9
cm to the left, and 9 cm further to the left of the paramedian incision,
with a 12 mm Assistant's port placed on the right side as well. Each is
placed with an extra-long Kelly clamp and a one inch malleable retractor
under direct palpation and directed into the pelvis.
The robotic instrument is docked in place, and a cautery scissors is
placed in the right hand, and a Maryland bipolar dissector in the left
hand, and a ProGrasp retractor in the far left hand. The fat overlying
the prostate is removed with the bipolar Maryland and the cautery scissors and discarded. An inverted "T" incision is made through the prostate and
pseudocapsule until the adenoma is encountered. The pseudocapsule is
elevated off the underlying adenoma laterally on left and right sides, and
also the bladder neck is pulled off the adenoma until the bladder neck
mucosal fibers are seen, and the mucosa is divided. A tenaculum is used
in the far left hand, and the adenoma is elevated out of the prostatic
fossa. The junction between the pseudocapsule and the adenoma is
identified and separated freeing the adenoma up laterally posteriorly
until the apex is encountered. The posterior lip of the bladder neck
mucosa was divided with the scissors as is the mucosa of the apex where
the urethra is. The adenoma is then completely freed, placed in an Endo
Catch bag, and will be retrieved at the end of the case.
With the ProGrasp retractor back into the far left hand, the prostatic
fossa is cauterized with the coagulating electrocautery with the cautery
scissors, and two needle drivers used to place a figure-of-8 sutures at
the 4 o'clock and 8 o'clock positions where the vascular pedicles enter.
Then 2-0 sutures are used to evert bladder neck mucosa into the fossa
which meets up with the urethral mucosa. The bladder neck mucosa is
everted with 3-0 interrupted sutures circumferentially.
All needles are successfully retrieved from the abdomen. A 22-French,
three-way Foley catheter is inserted and inflated with 50 mL of sterile
water. The pseudocapsule is closed with two separate running sutures of 2-
0 Vicryl. At the conclusion, the Foley catheter is irrigated, and the
color of the irrigant return is light pink. The Foley catheter is left
continuous irrigation, and a 15-French Jackson-Pratt drain is passed
through the left-sided medial robotic port and left overlying the
capsulotomy.
All the instruments are removed. The robotic instrument is undocked, and
the ports are removed. The prostate is retrieved through the paramedian
incision with the previously placed Endo Catch bag and is sent to
pathology laboratory for evaluation. The paramedian incision is closed
with 0 Vicryl sutures both at the fascial and subcutaneous layers. All
port sites are copiously irrigated with antibiotic saline and closed with
Indermil skin glue. The Jackson-Pratt drain is secured with a 0 Vicryl
suture, and left to bulb drainage, and the Foley catheter is left to
continuous irrigation drainage. The patient is then reversed from anesthesia, brought to the recovery area in awake, alert, and in stable
condition having tolerated the procedure well.