aguelfi
Guest
The doctor did a surgery below and I wanted to make sure I'm not missing anything. I coded 33533, 33517 and 33508. I think I should also us a 22 on teh 33533 due to the complexity but I was hoping for others opinions. I know this is really long but any help would be appreciated.
thanks
The vein was harvested from the lower extremity using endoscopic vein harvesting. The leg was closed in layers after that. A small incision was made in the right groin, the femoral artery was exposed, and 5-0 Prolene cannulation sutures were inserted.
An approximately 1-cm incision was made in the 4th intercostal space lateral to the nipple and just a few centimeters above the anterior axillary line. A camera port was inserted and CO2 insufflation was started. The camera was then sutured to the port and a good visualization of the left hemithorax was obtained. Next, a 5-mm port was inserted 4 fingerbreadths above in the 3rd costal space, approximately just lateral to the mid clavicular line. This 5-mm port was inserted under camera vision. A second 5-mm port was inserted 4 fingerbreadths inferior to the camera port and in the mid clavicular line, approximating the 6th intercostal space. After that, the robot was docked. Once the robot was docked, the camera was again inserted with the instrument of the spatula on the right and fine pickups on the left side. The mammary artery harvesting was then started with the robot. The mammary artery harvesting was completed without any difficulty. The mammary artery was completely skeletonized. The artery was divided distally and checked for flows, which were excellent. The mammary artery was then clipped at the end and positioned in the pericardial phrenic angle, approximately just above the pulmonary artery. The distal end was clipped multiple times. The distal end of the divided artery (towards the chest wall) was clipped multiple times.
Next, the instruments were changed and we started with a pericardial fat dissection, which was completed without any problems. Next, the pericardium was opened. However, once the small area of pericardium was opened, it was identified that the pericardium had intense adhesions to the heart. At that time, a decision was made that it would be safer to proceed with direct vision through a thoracotomy and not to proceed with robotic dissection of the pericardium (since there were dense adhesions). The robot was then docked and the ports removed.
A lateral thoracotomy was performed extending to the camera port in the 4th intercostal space. The retractor was inserted and a pericardial incision was performed. As mentioned, there were dense adhesions. Therefore, with sharp and blunt dissection, the pericardium was freed from the lateral wall down to the pulmonary veins. Superiorly the left atrium was identified. We continued superiorly and the pulmonary artery and aorta were free from dissection. Dissection was carried on to the right lateral aspect of the aorta as well. At that time, when I digitally palpated the aorta, it was completely calcified all around anteriorly and on the left lateral aspect, like a porcelain aorta. At that time, the TEE was reevaluated and confirmed that there were dense heavy calcifications on the aorta in the ascending part, and the arch and descending aorta as well. This brought us to the position that the patient would not be a candidate for a proximal anastomosis. In addition, if need to cross-clamp, that would not be a good idea and, therefore, a sternotomy would not be in place. In addition, if needed to occlude the aorta with endo-occlusion balloon, this would be a contraindication because of the dense calcifications in the ascending, arch and descending aorta itself. At that time, since we could not do a proximal anastomosis because of the heavy calcification on the ascending aorta, therefore, an alternate site for the proximal anastomosis was to be determined. Once option was to do a T-graft from the left internal mammary artery and the second option was to take the graft off the subclavian artery. Therefore, an incision was made in the left infraclavicular area and dissection continued through the pectoralis muscle and the left subclavian artery was identified. The brachioplexus was identified and preserved. The proximal and distal control was obtained and an arteriotomy was performed. This was followed by end-to-side vein to the artery anastomosis using 6-0 Prolene. The vein was further secured to the adventitia separately with 5-0 Prolene beyond the anastomosis so that there was no pull on the vein from the thoracic cavity. The vein was then inserted into the thoracic cavity and brought out next to the pericardial recess on the lateral wall of the heart. In addition, the vein was secured to the pericardium using 5-0 Prolene as well. We continued dissection inferiorly down to the apex.
It should be noted the patient was completely heparinized before dividing the mammary artery. ACT was kept above 450. Next, we proceeded with cannulation of the femoral artery and the femoral vein. This was performed using Seldinger technique and under TEE guidance. Once the cannulation sites were secured, cardiopulmonary bypass was initiated. Next, with the heart completely decompressed, we continued our dissection of the pericardium and the pericardium was completely freed off from the inferior wall of the diaphragm as well. At this time, we had the whole lateral wall in front of us and anterior wall as well. The diagonal artery was identified. However, the LAD was completely intramyocardial in the groove. However, with dissection and the hand-port stabilizer, we were able to easily dissect out the left anterior descending artery. However, on the lateral wall, because of dissection from previous adhesions, there were scar tissues and it was very difficult to identify any of the obtuse marginal arteries. As I mentioned earlier, there was a large circumflex artery. However, the distal vessels coming laterally on the wall were getting smaller. They were completely intramyocardial. However, we continued our dissection. At one point, I thought about just proceeding with a left internal mammary artery, left anterior descending artery anastomosis and requested the cardiologist to stent the circumflex artery. As mentioned earlier, the patient had a GI bleed and stenting would have been a very easy option. However, keeping in mind anticoagulation requirement after the stenting, it was decided not to proceed with that option. Therefore, we continued our dissection for exploration for the obtuse marginal artery. Thus, we were able to find a 1-mm distal branch, which would coincided with one of the few small branches coming off the main circumflex artery. He was stabilized, since the heart was beating and on pump. In addition, we slowed down the heart rate with esmolol drip. The 1-mm artery was dissected out and proximal and distal control was obtained using snares. Once an arteriotomy was performed, we inserted a 1-mm probe distally. This was followed by an end-to-side vein to the artery anastomosis using 7-0 Prolene.
Once that was completed, we proceeded with dissection of the left anterior descending artery. As I mentioned, it was also intramyocardial. However, we were easily able to dissect it. Proximal and distal control was obtained and an arteriotomy was performed followed by end-to-side left internal mammary artery, left anterior descending artery anastomosis using 7-0 Prolene.
thanks
The vein was harvested from the lower extremity using endoscopic vein harvesting. The leg was closed in layers after that. A small incision was made in the right groin, the femoral artery was exposed, and 5-0 Prolene cannulation sutures were inserted.
An approximately 1-cm incision was made in the 4th intercostal space lateral to the nipple and just a few centimeters above the anterior axillary line. A camera port was inserted and CO2 insufflation was started. The camera was then sutured to the port and a good visualization of the left hemithorax was obtained. Next, a 5-mm port was inserted 4 fingerbreadths above in the 3rd costal space, approximately just lateral to the mid clavicular line. This 5-mm port was inserted under camera vision. A second 5-mm port was inserted 4 fingerbreadths inferior to the camera port and in the mid clavicular line, approximating the 6th intercostal space. After that, the robot was docked. Once the robot was docked, the camera was again inserted with the instrument of the spatula on the right and fine pickups on the left side. The mammary artery harvesting was then started with the robot. The mammary artery harvesting was completed without any difficulty. The mammary artery was completely skeletonized. The artery was divided distally and checked for flows, which were excellent. The mammary artery was then clipped at the end and positioned in the pericardial phrenic angle, approximately just above the pulmonary artery. The distal end was clipped multiple times. The distal end of the divided artery (towards the chest wall) was clipped multiple times.
Next, the instruments were changed and we started with a pericardial fat dissection, which was completed without any problems. Next, the pericardium was opened. However, once the small area of pericardium was opened, it was identified that the pericardium had intense adhesions to the heart. At that time, a decision was made that it would be safer to proceed with direct vision through a thoracotomy and not to proceed with robotic dissection of the pericardium (since there were dense adhesions). The robot was then docked and the ports removed.
A lateral thoracotomy was performed extending to the camera port in the 4th intercostal space. The retractor was inserted and a pericardial incision was performed. As mentioned, there were dense adhesions. Therefore, with sharp and blunt dissection, the pericardium was freed from the lateral wall down to the pulmonary veins. Superiorly the left atrium was identified. We continued superiorly and the pulmonary artery and aorta were free from dissection. Dissection was carried on to the right lateral aspect of the aorta as well. At that time, when I digitally palpated the aorta, it was completely calcified all around anteriorly and on the left lateral aspect, like a porcelain aorta. At that time, the TEE was reevaluated and confirmed that there were dense heavy calcifications on the aorta in the ascending part, and the arch and descending aorta as well. This brought us to the position that the patient would not be a candidate for a proximal anastomosis. In addition, if need to cross-clamp, that would not be a good idea and, therefore, a sternotomy would not be in place. In addition, if needed to occlude the aorta with endo-occlusion balloon, this would be a contraindication because of the dense calcifications in the ascending, arch and descending aorta itself. At that time, since we could not do a proximal anastomosis because of the heavy calcification on the ascending aorta, therefore, an alternate site for the proximal anastomosis was to be determined. Once option was to do a T-graft from the left internal mammary artery and the second option was to take the graft off the subclavian artery. Therefore, an incision was made in the left infraclavicular area and dissection continued through the pectoralis muscle and the left subclavian artery was identified. The brachioplexus was identified and preserved. The proximal and distal control was obtained and an arteriotomy was performed. This was followed by end-to-side vein to the artery anastomosis using 6-0 Prolene. The vein was further secured to the adventitia separately with 5-0 Prolene beyond the anastomosis so that there was no pull on the vein from the thoracic cavity. The vein was then inserted into the thoracic cavity and brought out next to the pericardial recess on the lateral wall of the heart. In addition, the vein was secured to the pericardium using 5-0 Prolene as well. We continued dissection inferiorly down to the apex.
It should be noted the patient was completely heparinized before dividing the mammary artery. ACT was kept above 450. Next, we proceeded with cannulation of the femoral artery and the femoral vein. This was performed using Seldinger technique and under TEE guidance. Once the cannulation sites were secured, cardiopulmonary bypass was initiated. Next, with the heart completely decompressed, we continued our dissection of the pericardium and the pericardium was completely freed off from the inferior wall of the diaphragm as well. At this time, we had the whole lateral wall in front of us and anterior wall as well. The diagonal artery was identified. However, the LAD was completely intramyocardial in the groove. However, with dissection and the hand-port stabilizer, we were able to easily dissect out the left anterior descending artery. However, on the lateral wall, because of dissection from previous adhesions, there were scar tissues and it was very difficult to identify any of the obtuse marginal arteries. As I mentioned earlier, there was a large circumflex artery. However, the distal vessels coming laterally on the wall were getting smaller. They were completely intramyocardial. However, we continued our dissection. At one point, I thought about just proceeding with a left internal mammary artery, left anterior descending artery anastomosis and requested the cardiologist to stent the circumflex artery. As mentioned earlier, the patient had a GI bleed and stenting would have been a very easy option. However, keeping in mind anticoagulation requirement after the stenting, it was decided not to proceed with that option. Therefore, we continued our dissection for exploration for the obtuse marginal artery. Thus, we were able to find a 1-mm distal branch, which would coincided with one of the few small branches coming off the main circumflex artery. He was stabilized, since the heart was beating and on pump. In addition, we slowed down the heart rate with esmolol drip. The 1-mm artery was dissected out and proximal and distal control was obtained using snares. Once an arteriotomy was performed, we inserted a 1-mm probe distally. This was followed by an end-to-side vein to the artery anastomosis using 7-0 Prolene.
Once that was completed, we proceeded with dissection of the left anterior descending artery. As I mentioned, it was also intramyocardial. However, we were easily able to dissect it. Proximal and distal control was obtained and an arteriotomy was performed followed by end-to-side left internal mammary artery, left anterior descending artery anastomosis using 7-0 Prolene.