Dural resection and reconstruction

Diana29

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I need help with the code for the dural resection please.





PROCEDURE PERFORMED:  Intraoperative dural resection of abnormally
thickened and involved dura and primary dural closure using
temporalis fascia.

INDICATIONS:  The patient is a 60-year-old gentleman who was
initially diagnosed in 2016 with right frontal squamous cell
carcinoma and had his Mohs procedure.  It grew back and became quite
large and then recurred and had radiation and chemotherapy.  He has
had local recurrence and is felt to be a good candidate for resection
and turning a temporalis flap.

I was asked to be involved to resect or if needed during the
procedure.  I was consulted intraoperatively.  Dr. XXX sent
few specimens of dura for frozen section, which were involved with
tumor.  Dr. XXX did show me the border where he had removed
bone and where the normal dura and the abnormal dura was resected
using a #15-blade knife and Metzenbaum scissors.  The dura was sent
for specimen. A piece of temporalis fascia was cut to about the same
size and then sutured primarily using 4-0 Nurolon sutures in simple
interrupted style as well as running simple style.  A Valsalva was
performed and there was a watertight closure.  Wound was irrigated
and then the remaining closure was performed by Dr. XXX.



Another surgeon also performed the following procedures during the same operative session:

POSTOPERATIVE DIAGNOSIS:  Right forehead, calvarium, and dural​
carcinoma


PROCEDURES:
1.  Radical resection, right forehead and supraorbital malignancy 5
cm in diameter.
2.  Right frontal craniectomy.
3.  Dural resection and reconstruction.
4.  Right temporalis flap.​
5.  Adjacent tissue transfer reconstruction and AlloDerm grafting.




Under loupe magnification, I marked out an area of the forehead with
normal-appearing skin margins around a large exophytic mass involving
the forehead and supraorbital region.  The patient's eyelids had
already been aggressively surgically managed by oculoplastic surgery.
 I placed an adequate Lacrilube and taped the left side.  A drew out
a series of advancement flaps superior and lateral to the area for
future reconstruction.  I incised the skin and subcutaneous tissues
with a 15 blade and came straight down to the calvarium and the
supraorbital rim.  Bleeding was controlled as was encountered.  I
aggressively dissected the entire forehead and supraorbital region
with a diameter of about 5.5 cm of skin, subcutaneous tissue, and
large volume of very firm and exophytic mass, and brought this all
the way off the calvarium inclusive of the periosteum.  I used the
periosteal elevator as well as blunt dissection.  Once I brought this
inferiorly to the supraorbital rim, I separated the skin and
subcutaneous tissue and mass away from the upper eyelid and
essentially came right down onto the periorbita.  I removed the
entire tumor mass.  I then did a series of frozen section margins and
the skin around the defect and sent this for pathology.

I carefully inspected the calvarium.  There was a defect about 2 cm
in diameter, full-thickness fashion with tumor extending down to the
dura.  Surrounding this, there was a large zone of soft moth-eaten
bone that was clearly abnormal.  I used a series of instruments.  I
used a Freer elevator to bluntly dissect large pieces of free bone as
well as tumor, I used multiple sized Kerrisons, I used a 4 mm cutting
bur on the TPS drill to perform a fairly large area of craniectomy
with removal of about an area of 6 cm wide x 5 cm high inclusive of
the supraorbital rim all of this bone.  I carefully identified the
dura during this entire dissection and elevated on this separating
the dura from the bone.  I also aggressively dissected into the orbit
elevating much of the supraorbital rim and bone away from the
periorbita along the entire superior orbit.  I removed about 2 cm of
not just supraorbital rim, but down into the roof of the orbit and
had a nice clean plane between the intact dura and intact periorbita.
 I had a large full-thickness defect of the calvarium.  Bleeding was
controlled as it was encountered.

I carefully inspected the dura.  Just underneath the area of the
tumor involvement in the zone of about 3.5 to 4 cm in diameter, the
dura was somewhat thickened and slightly discolored relative to the
more healthy appearing dura underneath the area that I had elevated
and removed, intact calvarium.  I did a biopsy of this dura as a deep
margin with a 15 blade in a partial thickness fashion.  I sent this
for frozen section, which revealed invasive carcinoma.

I consulted with Dr. XXX who came in and under loupe
magnification, we agree on the zone of dural resection and cooperated
all the abnormal changes visibly and had a margin of normal appearing
dura circumferentially.  She incised and removed this dura in a
full-thickness fashion.  The underlying brain parenchyma looked
completely normal.  This dura was sent for analysis.  We then
harvested temporalis fascia and she performed a large temporalis
fascia graft or dural reconstruction as dictated under separate
operative report.  This was intact at the end of the procedure
without evidence of CSF leakage.

At this point, I undermined aggressively in the skin of the cheek
back to the ear and up higher over the calvarium.  I aggressively
exposed this with Army-Navy retractors and I identified and exposed
the entire temporalis muscle from the temporal fossa.  I incised this
distally with electrocautery and elevated the entire temporalis
muscle from the temporal fossa down to the zygoma.  I skeletonized
the zygomatic arch and the lateral orbital rim, and elevated
underneath this to increase laxity of the temporalis muscle.  I also
made a back-cut in the temporalis muscle at the level just behind and
inferior to the zygomatic arch.  With all these maneuvers, I was able
to rotate the entire temporalis muscle anteriorly to cover over the
entire reconstruction.  Bleeding was controlled as was encountered.

Once I rotated the temporalis muscle in position, I inset this
utilizing interrupted 3-0 Vicryl sutures and attached this anywhere I
could, the pericranium as well as the subcutaneous tissues to
completely drape this over the dural reconstruction and the
craniectomy defect.  I placed Tisseel over the dural reconstruction
underneath the temporalis muscle to help create a second adherent
layer reconstruction over the dural reconstruction.  I inset the
entire temporalis muscle with interrupted 3-0 Vicryl sutures.

Next, I narrowed down my large cutaneous defect with #2 techniques.
I did a large advancement flap from the posterior facial and scalp
wound.  I dropped a curvilinear incision posteriorly to create a
large flap 4 x 10 cm and advance this anteriorly and slide this into
position.  This was inset further anteriorly and split forward with
interrupted 3-0 Vicryl sutures.  This narrowed down the defect
considerably.  I then selected a thin piece of AlloDerm 4 x 2 cm, and
ultimately used 2 pieces of this.  I pie-crusted this and placed this
over the temporalis muscle.  I inset this to the surrounding
cutaneous areas including the upper eyelid as well as the midline
forehead and the advancement flap skin.  This was done with
interrupted 3-0 Vicryl sutures.  Much of these were left long.  Once
I had the AlloDerm graft completely inset, I placed a large bolster
of Xeroform gauze over the AlloDerm graft and secured this with the
tie-over sutures.  I placed a JP drain in the scalp in the
postauricular region to drain the temporalis donor site.  This was
placed in bulb suction.  The patient was then awakened and extubated.​
There were no complications.
 

ibetiger

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I would go with 61510 - as that covers all brain tumors regardless if the tumor is on the surface of the brain or further into the brain matter. It also includes dural repair and cranioplasty. Adjacent flap harvested from same incision site is included as well.


Dr. X vs Dr Z coding - the question would be are they the same practice? If so, and if documented properly you could bill assistant physician for the doc called in. If separate specialties then co-surgery may be applicable.
 
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