hcg
Guru
I chose to code 32663 for this procedure, but need a second opinion. All opinions are greatly appreciated. Thank you.
***************************************************************
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the right lower lobe of the lung.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the right lower lobe of the lung.
SURGEON: Dr. A
ASSISTANT: Dr. B
ANESTHESIOLOGIST:
ANESTHESIA:
OPERATION: Flexible bronchoscopy with thoracoscopy/thoracotomy, right upper lobectomy, mediastinal perihilar node dissection.
INDICATIONS FOR SURGERY
The patient is an 81-year-old, reformed smoker, with radiographic findings of right lower lobe lung mass, confirmed on CT scan. Further evaluation including CT guided needle biopsy demonstrating squamous cell carcinoma, followed by PET CT scan, which confirmed increased metabolic activity within the mass, SUV of 8, and a small node adjacent to the junction of the trachea and right upper lobe bronchus, with SUV of 1.8. The patient was seen in surgical consultation and following lengthy interview, examination, review of all of his studies, surgical resection was advised. The presence of the slightly active perihilar lymph node discussed at length with the patient and his family as to the significance of its presence as to the staging of the underlying lesion as well as the optional evidence for it, ranging from further efforts at identifying tumor within this node followed by perioperative radiotherapy/chemotherapy of 5 to 6 weeks, followed by 5 to 6 weeks of observation, the assessment and possible surgical resection versus preceding directly with right lower lobectomy and mediastinal node dissection. The risks and benefits of both of these approaches were discussed with the patient and his family at length. The patient himself was anxious to proceed with surgery, wishing as little delay as possible, and this was scheduled accordingly.
DESCRIPTION OF PROCEDURE
On arrival in the operating room, the patient and surgical site were identified. Under general double lumen endotracheal anesthesia, the flexible bronchoscope was passed. The carina was sharp and midline. No endobronchial lesions could be noted to the subsegmental level. Following positioning of the endotracheal tube and placement of appropriate monitoring lines, the patient was placed in left lateral decubitus position, carefully padding all pressure points and prepped and draped so as to expose the right chest. Following the standard time out for patient and surgical site re-identification, a 1 cm incision was made in the right lateral fifth interspace and the pleural cavity entered. A 5 mm trocar was inserted and the 30 degree 5 mm thoracoscope introduced. The lung was soft and pliable with moderate <____________________> changes superficially. The lesion in question could not be identified fluoroscopically. No evidence of parietal pleural involvement was noted. It was therefore elected to proceed with thoracotomy and surgical resection. The scope and trocar were removed. A right fifth intercostal lateral incision was made incorporating the previous incision incising the lateral margin of the pectoralis major muscle, retracting with latissimus dorsi and serratus muscles posteriorly, and incising the intercostal muscles throughout their length. The rib spreader was inserted and gradually expanded to afford exposure. Palpation of the lower lobe demonstrated the mass about its mid portion, estimated about 4 cm in diameter. No other parenchymal involvement was noted. The inferior pulmonary ligament was divided and the perihilar pleura incised. A cluster of black matted nodes were palpable within the posterior peribronchial area. The inferior pulmonary vein was isolated and looped with a 0 silk ligature. The major fissure was carefully dissected using sharp dissection with cautery and completed with several serial applications of the Universal stapler using 3.5 staples. The arterial segments to the lower lobe were identified and dissected out with 0 silk ligature and ligated with the Universal vascular stapler. The bronchial segments to the lower lobe identified and dissected, carefully identifying the bronchial segment to the middle, which was preserved. The bronchial segments were then secured with the TA 34.8 stapler. Then the upper and middle lobe were inflated to demonstrate patency of the remaining bronchi. The bronchus was then transected and the specimen removed. Identifying the medial segments with sutures for pathologic examination. A cluster of black matted lymph nodes within the posterior medial parahilar area were dissected en bloc, marked cephalad with silk suture. The direct mediastinal node anteriorly was dissected out and sent separately for pathologic examination. No other mediastinal lymphadenopathy could be identified. The specimens were hand carried to pathology, where pathologic examination of the bronchial segments demonstrated no evidence of involvement. Then two 36 chest tubes were placed under direct vision within the apex of the inferior sulcus and brought out through separate incisions, securely sutured and connected to dry suction at minus 40 mmHg. The lung was inflated underwater and some parenchymal air leak in the peribronchial area of the right middle lobe were noted. These were felt to be inconsequential. No bronchial stump air leaks were detected. Correct sponge and instrument count. The incision was closed using 2 Vicryl figure-of-eight pericostal sutures, followed by running 0 Vicryl to the muscle layer and 2-0 Prolene subcuticular sutures closed the skin. Dry dressing was applied. The patient repositioned supine, extubated and returned to the recovery room in stable condition.
***************************************************************
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the right lower lobe of the lung.
POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma of the right lower lobe of the lung.
SURGEON: Dr. A
ASSISTANT: Dr. B
ANESTHESIOLOGIST:
ANESTHESIA:
OPERATION: Flexible bronchoscopy with thoracoscopy/thoracotomy, right upper lobectomy, mediastinal perihilar node dissection.
INDICATIONS FOR SURGERY
The patient is an 81-year-old, reformed smoker, with radiographic findings of right lower lobe lung mass, confirmed on CT scan. Further evaluation including CT guided needle biopsy demonstrating squamous cell carcinoma, followed by PET CT scan, which confirmed increased metabolic activity within the mass, SUV of 8, and a small node adjacent to the junction of the trachea and right upper lobe bronchus, with SUV of 1.8. The patient was seen in surgical consultation and following lengthy interview, examination, review of all of his studies, surgical resection was advised. The presence of the slightly active perihilar lymph node discussed at length with the patient and his family as to the significance of its presence as to the staging of the underlying lesion as well as the optional evidence for it, ranging from further efforts at identifying tumor within this node followed by perioperative radiotherapy/chemotherapy of 5 to 6 weeks, followed by 5 to 6 weeks of observation, the assessment and possible surgical resection versus preceding directly with right lower lobectomy and mediastinal node dissection. The risks and benefits of both of these approaches were discussed with the patient and his family at length. The patient himself was anxious to proceed with surgery, wishing as little delay as possible, and this was scheduled accordingly.
DESCRIPTION OF PROCEDURE
On arrival in the operating room, the patient and surgical site were identified. Under general double lumen endotracheal anesthesia, the flexible bronchoscope was passed. The carina was sharp and midline. No endobronchial lesions could be noted to the subsegmental level. Following positioning of the endotracheal tube and placement of appropriate monitoring lines, the patient was placed in left lateral decubitus position, carefully padding all pressure points and prepped and draped so as to expose the right chest. Following the standard time out for patient and surgical site re-identification, a 1 cm incision was made in the right lateral fifth interspace and the pleural cavity entered. A 5 mm trocar was inserted and the 30 degree 5 mm thoracoscope introduced. The lung was soft and pliable with moderate <____________________> changes superficially. The lesion in question could not be identified fluoroscopically. No evidence of parietal pleural involvement was noted. It was therefore elected to proceed with thoracotomy and surgical resection. The scope and trocar were removed. A right fifth intercostal lateral incision was made incorporating the previous incision incising the lateral margin of the pectoralis major muscle, retracting with latissimus dorsi and serratus muscles posteriorly, and incising the intercostal muscles throughout their length. The rib spreader was inserted and gradually expanded to afford exposure. Palpation of the lower lobe demonstrated the mass about its mid portion, estimated about 4 cm in diameter. No other parenchymal involvement was noted. The inferior pulmonary ligament was divided and the perihilar pleura incised. A cluster of black matted nodes were palpable within the posterior peribronchial area. The inferior pulmonary vein was isolated and looped with a 0 silk ligature. The major fissure was carefully dissected using sharp dissection with cautery and completed with several serial applications of the Universal stapler using 3.5 staples. The arterial segments to the lower lobe were identified and dissected out with 0 silk ligature and ligated with the Universal vascular stapler. The bronchial segments to the lower lobe identified and dissected, carefully identifying the bronchial segment to the middle, which was preserved. The bronchial segments were then secured with the TA 34.8 stapler. Then the upper and middle lobe were inflated to demonstrate patency of the remaining bronchi. The bronchus was then transected and the specimen removed. Identifying the medial segments with sutures for pathologic examination. A cluster of black matted lymph nodes within the posterior medial parahilar area were dissected en bloc, marked cephalad with silk suture. The direct mediastinal node anteriorly was dissected out and sent separately for pathologic examination. No other mediastinal lymphadenopathy could be identified. The specimens were hand carried to pathology, where pathologic examination of the bronchial segments demonstrated no evidence of involvement. Then two 36 chest tubes were placed under direct vision within the apex of the inferior sulcus and brought out through separate incisions, securely sutured and connected to dry suction at minus 40 mmHg. The lung was inflated underwater and some parenchymal air leak in the peribronchial area of the right middle lobe were noted. These were felt to be inconsequential. No bronchial stump air leaks were detected. Correct sponge and instrument count. The incision was closed using 2 Vicryl figure-of-eight pericostal sutures, followed by running 0 Vicryl to the muscle layer and 2-0 Prolene subcuticular sutures closed the skin. Dry dressing was applied. The patient repositioned supine, extubated and returned to the recovery room in stable condition.
