MariaGraham73
New
Hello Melanie and All!
Melanie or anyone, do you have any CPT suggestions for the following Surgery?
Indications for Procedure:
Ms. X is a 74 yo female with history of Breast, Uterine MMMT and Colon cancers.
She has a pre sacral mass s/p IR guided biopsy, results negative for malignancy.
Repeat PET showing the sacral mass increasing in size
She has urinary incontinence likely Mass effect.
Plan for XLAP tumor debulking.
Estimated Blood Loss: Estimated 250 mL
Operative findings: Large necrotic pelvic mass in the pre sacral space invading the entire vagina and the posterior wall of the bladder encasing both ureters. Frozen section confirmed mesenchymal tumor likely uterine origin. Extensive small bowel adhesions in the abdomen and pelvis.
Procedure Details:
After obtaining and verifying informed consent, time out was completed to verify correct patient procedure and site. General anesthesia was administered and noted to be adequate. Patient was then prepared and draped in the usual sterile fashion in the dorsal lithotomy position in the yellowfin stirrups with her arms carefully padded on arm boards, careful attention paid not to hyperextend her arms. A foley catheter was placed. Attention was turned to the abdominal portion of the procedure. A vertical skin incision was then made with a scalpel beginning at the pubic symphysis and continuing to above the umbilicus. The underlying subcutaneous tissue was opened with the Bovie and the fascia incised in the midline with the Bovie. The peritoneum was visibly evident and entered. The incision was then continued superiorly and inferiorly with the Bovie with good visualization of bowel and bladder. The Bookwalter retractor was then placed at this time with careful attention to retractor placement. The small bowel was packed out of the pelvis and the pelvic mass was visualized. The mass invading the posterior part of the bladder and entire vagina.
The right round ligament was suture ligated with 0 vicryl suture. The right retroperitoneal space was entered and the ureter was identified in the retroperitoneal space. The left retroperitoneal space was then entered, and the ureter was identified in the retroperitoneal space and a window was created below the IP ligament and above the ureter. A vessel loop was applied to the left ureter. Bilateral ureterolysis were performed to the course of the ureters in the pelvis.
Biopsy from necrotic mass confirmed mesenchymal malignancy likely from uterus. The mass was encasing both ureters and decision was made for radical vaginectomy and cystectomy to debulk the disease.
Extensive small bowel adhesions with Dr. X yo release the bowel from the pelvis.
The bowel was then packed out of the pelvis for initiation of the exenterated portion of the procedure. The iliac vessels as well as the ureters were well visualized bilaterally. The paravesical spaces were opened bilaterally and bilateral ureterolysis was
completed beginning near the bifurcation of the iliac vessels and continuing to
approximately 3 cm above the bladder. The ureters were freed laterally as well
as inferiorly. The space of Retzius was entered anteriorly as the bladder was identified. The
space was entered with the Bovie and the plane developed just below the level
of the pubic symphysis. The specimen was then freed anteriorly using the
ligasure instrument. Additional lateral attachments abutting the pelvic
sidewall were taken down using the LigaSure instrument as well. The lateral edges of the pelvic sidewall were entered with the Bovie to identify the margin of the tumor from the abdominal approach. The attachments were taken down laterally using the LigaSure instrument. the dissection was continued more laterally to abut the left pelvic sidewall at the level of the bone itself. The ureters were then tied of distally then incised distal to the suture with Metzenbaum scissors.
The specimen including pelvic mass, vagina, bladder, distal ureters and urethra were sent for pathology.
There was a large right external iliac pelvic lymph node dissection was then performed in the usual manner. The borders were as follows: Medial border was the ureter and the superior vesicle artery, lateral border was the genitofemoral nerve along the psoas muscle, the cephalad border was lower common iliac nodes, the caudad border was the superficial circumflex iliac vein, the deep border was the obturator nerve within the obturator space. Excellent hemostasis was appreciated on completion of the bilateral nodal dissection.
Omental adhesions to the pelvis. The omentum was then removed in an infracolic fashion with blunt, sharp, bovie and Ligasure cautery. No significant thickening or tumor nodularity was noted within the omentum. The site of the omentectomy and its pedicles were examined and noted to be hemostatic.
All remaining laps were then removed from the abdomen and the pelvis was copiously irrigated and cleared with saline.
The small bowel was then examined in its entirety beginning at the ileocecal junction and continuing to the ligament of Treitz and noted to be without evidence of disease or trauma.
The colon was also examined from the ileocecal junction through the sigmoid colon and the rectum and noted to be without evidence of trauma or disease. The bowel was then returned to its native confirmation. All retractors were removed at this time.
The fascia was then closed with #1 PDS loop x2 in a running fashion. The subcutaneous tissue was irrigated and cleared of all clots and debris and the skin was then closed with staples and a sterile dressing was then applied.
The patient tolerated the procedure well without complications.
Sponge, lap, instrument and needle counts were correct x2. The patient did receive antibiotics which were re-dosed appropriately intraoperatively.
By the end of the procedure there was no evidence of any gross residual disease in the abdomen and pelvis and no evidence of any injuries to any organs in the abdomen and pelvis.
Thanks so much for your help.
Melanie or anyone, do you have any CPT suggestions for the following Surgery?
Indications for Procedure:
Ms. X is a 74 yo female with history of Breast, Uterine MMMT and Colon cancers.
She has a pre sacral mass s/p IR guided biopsy, results negative for malignancy.
Repeat PET showing the sacral mass increasing in size
She has urinary incontinence likely Mass effect.
Plan for XLAP tumor debulking.
Estimated Blood Loss: Estimated 250 mL
Operative findings: Large necrotic pelvic mass in the pre sacral space invading the entire vagina and the posterior wall of the bladder encasing both ureters. Frozen section confirmed mesenchymal tumor likely uterine origin. Extensive small bowel adhesions in the abdomen and pelvis.
Procedure Details:
After obtaining and verifying informed consent, time out was completed to verify correct patient procedure and site. General anesthesia was administered and noted to be adequate. Patient was then prepared and draped in the usual sterile fashion in the dorsal lithotomy position in the yellowfin stirrups with her arms carefully padded on arm boards, careful attention paid not to hyperextend her arms. A foley catheter was placed. Attention was turned to the abdominal portion of the procedure. A vertical skin incision was then made with a scalpel beginning at the pubic symphysis and continuing to above the umbilicus. The underlying subcutaneous tissue was opened with the Bovie and the fascia incised in the midline with the Bovie. The peritoneum was visibly evident and entered. The incision was then continued superiorly and inferiorly with the Bovie with good visualization of bowel and bladder. The Bookwalter retractor was then placed at this time with careful attention to retractor placement. The small bowel was packed out of the pelvis and the pelvic mass was visualized. The mass invading the posterior part of the bladder and entire vagina.
The right round ligament was suture ligated with 0 vicryl suture. The right retroperitoneal space was entered and the ureter was identified in the retroperitoneal space. The left retroperitoneal space was then entered, and the ureter was identified in the retroperitoneal space and a window was created below the IP ligament and above the ureter. A vessel loop was applied to the left ureter. Bilateral ureterolysis were performed to the course of the ureters in the pelvis.
Biopsy from necrotic mass confirmed mesenchymal malignancy likely from uterus. The mass was encasing both ureters and decision was made for radical vaginectomy and cystectomy to debulk the disease.
Extensive small bowel adhesions with Dr. X yo release the bowel from the pelvis.
The bowel was then packed out of the pelvis for initiation of the exenterated portion of the procedure. The iliac vessels as well as the ureters were well visualized bilaterally. The paravesical spaces were opened bilaterally and bilateral ureterolysis was
completed beginning near the bifurcation of the iliac vessels and continuing to
approximately 3 cm above the bladder. The ureters were freed laterally as well
as inferiorly. The space of Retzius was entered anteriorly as the bladder was identified. The
space was entered with the Bovie and the plane developed just below the level
of the pubic symphysis. The specimen was then freed anteriorly using the
ligasure instrument. Additional lateral attachments abutting the pelvic
sidewall were taken down using the LigaSure instrument as well. The lateral edges of the pelvic sidewall were entered with the Bovie to identify the margin of the tumor from the abdominal approach. The attachments were taken down laterally using the LigaSure instrument. the dissection was continued more laterally to abut the left pelvic sidewall at the level of the bone itself. The ureters were then tied of distally then incised distal to the suture with Metzenbaum scissors.
The specimen including pelvic mass, vagina, bladder, distal ureters and urethra were sent for pathology.
There was a large right external iliac pelvic lymph node dissection was then performed in the usual manner. The borders were as follows: Medial border was the ureter and the superior vesicle artery, lateral border was the genitofemoral nerve along the psoas muscle, the cephalad border was lower common iliac nodes, the caudad border was the superficial circumflex iliac vein, the deep border was the obturator nerve within the obturator space. Excellent hemostasis was appreciated on completion of the bilateral nodal dissection.
Omental adhesions to the pelvis. The omentum was then removed in an infracolic fashion with blunt, sharp, bovie and Ligasure cautery. No significant thickening or tumor nodularity was noted within the omentum. The site of the omentectomy and its pedicles were examined and noted to be hemostatic.
All remaining laps were then removed from the abdomen and the pelvis was copiously irrigated and cleared with saline.
The small bowel was then examined in its entirety beginning at the ileocecal junction and continuing to the ligament of Treitz and noted to be without evidence of disease or trauma.
The colon was also examined from the ileocecal junction through the sigmoid colon and the rectum and noted to be without evidence of trauma or disease. The bowel was then returned to its native confirmation. All retractors were removed at this time.
The fascia was then closed with #1 PDS loop x2 in a running fashion. The subcutaneous tissue was irrigated and cleared of all clots and debris and the skin was then closed with staples and a sterile dressing was then applied.
The patient tolerated the procedure well without complications.
Sponge, lap, instrument and needle counts were correct x2. The patient did receive antibiotics which were re-dosed appropriately intraoperatively.
By the end of the procedure there was no evidence of any gross residual disease in the abdomen and pelvis and no evidence of any injuries to any organs in the abdomen and pelvis.
Thanks so much for your help.
