Kstrobel
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Can anyone help me with CPT codes for this surgery?
Ear/Nose and Throat surgeon report
Procedure: 1. Coronal approach to anterior skull base 2. Cranialization of frontal sinuses 3. Transcranial exploration of right orbit with tumor removal 4. Pericranial flap with closure of CSF leak 5. Cranioplasty larger than 5 cm
Specimen: Intracranial mass, right orbital contents, dural margin
Estimated Blood Loss: 1100 ml
Indications for Procedure: The patient has a history of right frontal meningioma excised 2 years ago. Pathology was consistent with atypical meningioma. Surveillance imaging demonstrated recurrence.
Operative Findings: Large recurrent tumor involving the right frontal lobe, anterior and posterior tables of the right frontal sinus, right forehead soft tissues and right orbit.
Description of Procedure: The patient and his family were met in the preoperative area. Risks, benefits and alternatives of procedure were discussed and the patient and family wished to proceed patient was brought to the operating room and a lumbar drain and arterial line were placed. Patient was placed supine operative table and general anesthesia was induced via endotracheal tube. Dr. Wills place patient in a Mayfield headholder. The cranium and the right thigh were prepped and draped in the usual sterile fashion. A timeout was performed identifying the patient and the procedure. Patient's previous craniotomy incision was marked and injected with approximately 10 mL 1% lidocaine with 1 100,000 epinephrine. 10 blade was used to open the previous craniotomy incision and identify subgaleal supra-paricranial plane. In the left frontal region there was a robust and intact pericranial layer. Working his subgaleal plane the scalp flap was elevated. Once the region of the tumor extension through the previous craniotomy site was encountered the plane was switched to a supra-galeal plane within the substance of the frontalis muscle. A very small amount of frontalis muscle was left adherent to the tumor as the flap was elevated. Once the area of the tumor was passed a subgaleal plane was again established. The flap was elevated to the level of the superior orbital rims. The pericranial flap was then elevated. This was harvested in an L-shaped fashion taking some of the remnant pericranium superior to the tumor site on the right and involving the entire pericranial flap on the left. The flap was carefully elevated was then pedicled on the supratrochlear and supraorbital vascular bundles. Flap was carefully covered with moist gauze and kept moist throughout the entire case. Dr. Wills then proceeded with removing the previous hardware closing the craniotomy site and opening craniotomy. He then proceeded to enlarge the craniotomy site which involved both the right and left frontal sinuses. The posterior table of the left frontal sinus was not violated. He then proceeded to resect the intracranial portion of the tumor and repair of the dural defect. Following his removal intracranial portion of the tumor I proceeded to carefully remove all the mucosa from both frontal sinuses down into the frontal ostium and then the frontal recess and remove the posterior table the right frontal sinus. The intersinus septum was also removed. The posterior table of the left frontal sinus was left intact. The entire bony surface of the remaining walls of the frontal sinuses were drilled with a diamond bur to ensure no rests of mucosal tissue. There was evidence of thickening of the bone of the right orbital roof. This bone was soft and had evidence of tumor involvement. The involved bone of the right orbital roof was removed using a combination of Kerrison and Roger forceps. The periorbita was left intact. The bone was separated back to healthy bone. The vault of bone and tumor peeled away from the periorbita without difficulty and there was no evidence of invasion of the periorbita. Temporalis muscle was harvested from the deep surface of the right temporalis muscle. This muscle was then packed into the frontal recess bilaterally. The right orbital roof was reconstructed using a 0.3 mm titanium plate. This was trimmed to size and was secured into position with two 4 mm screws anteriorly into the posterior surface of the anterior table of the frontal sinus and one screw laterally. Dr. Wills harvested fat from the right thigh. No fascia lata was harvested. The previously planned Medpor implant was then trimmed to size to fit the craniotomy defect following tumor removal. The defect was larger than 5 cm. Care was taken to ensure that there was a wide enough opening inferiorly along the frontal bar to allow for the pericranial flap to drape into the sinus without restriction with extra space plan for any swelling of the flap. The pericranial flap was then laid over the frontal ostium bilaterally, draped over the right orbital roof and was tucked under the inferior dura along the floor of the anterior cranial fossa. There was a small CSF leak from the dura along the floor of the anterior cranial fossa which was addressed by laying the pericranial flap under the dura along the skull base and securing it posteirorly. The previously harvested fat was placed within the left frontal sinus and overlying the pericranial flap in the region of the frontal ostia. Tissue glue was then used to cover the dural repair in addition to the edges of the pericranial flap. The Medpor implant was secured into place using titanium mini plates and screws. The opening for the pericranial flap was again assessed and there was no evidence of restriction with all on the flap. Dr. Wilson placed a subgaleal drain. The coronal incision was closed in 2 layers, first with interrupted buried Vicryl sutures in the galeal layer followed by staples and the skin. Patient tolerated the procedure without immediate complication. The patient was transferred to the intensive care unit in stable condition.
Neurosurgeon op report
NAME OF PROCEDURE:
1. Bilateral revision redo frontal craniectomy for resection of recurrent atypical meningioma.
2. Bilateral frontal sinus extirpation.
3. Right leg fat graft.
4. Bifrontal cranioplasty with Medpor synthetic plate.
DESCRIPTION OF PROCEDURE:
Preoperatively, the patient had an MRI scan and CT scan performed. The MRI was performed with BrainLAB protocol. This showed a significant growth of the tumor since his previous scan of early December. The intracranial portion of the tumor had previously measured 2.5 cm in diameter. It now measured over 5 cm in diameter. There was deep extension into the right frontal lobe. Preoperatively, the patient had no new complaints, but his wife noted some short-term memory difficulty.
After the patient was brought to the operating room, he was anesthetized. His head was affixed in a Mayfield head holder. The head of the bed was brought up 20 degrees and the head positioned with the neck flexed and chin extended. The Mayfield was secured to the table. BrainLAB neuronavigation was registered to the patient's facial features with good accuracy. The scalp and face were then clipped, prepped, and draped in the usual sterile fashion. Dr. Meyers and I performed the exposure; 10 mL of 1% lidocaine with epinephrine was infiltrated into the skin. A bicoronal skin incision was performed utilizing his previous incision. We were able to identify pericranium and developed a plane between the galea and the pericranium reflecting the scalp anteriorly. Previously, I had employed an interfascial approach, which was revised. Both orbital rims were exposed, as was the nasion. Dr. Meyers was then able to elevate the vascularized pericranial flap. The extracranial extension of the tumor was palpable and visible. The scalp had been dissected off this extracranial extension of the tumor in a plane which appeared to be the right frontalis muscle.
Once the scalp had been reflected anteriorly and maintained in place with fishhook retractors, bipolar cautery was used to maintain hemostasis. Cautery was used to delineate the pericranium from the skull at the circular area of the external extension. Previous craniotomy cuts were identified. The previous bur-hole covers were removed. The previous right frontal craniotomy was revised with the osteotome and elevated atraumatically. The frontal sagittal sinus was re-exposed. There was additional frontal bone in the bone of the frontal sinuses which was extending around the tumor which invaded frontal bone. This was delineated from the dura circumferentially with the drill. The anterior wall of the frontal sinus was then removed with the drill. The posterior wall of the frontal sinus lip was left intact. The outer calvaria of the left frontal bone was removed with the drill to accommodate the patient's preformed cranioplasty plate.
Once all bone had been removed circumferentially from around the tumor where it protruded from the dura, I entered the tumor with an 11-blade knife and removed a piece and sent this to the pathologist who confirmed meningioma. The tumor was then debulked internally using the Sonopet ultrasonic aspirator. The tumor itself was soft and easily evacuated. When I had circumferentially and deeply evacuated the internal components of the tumor, additional specimens were sent from the deep portion of the tumor. I then opened the dura superior and lateral to the tumor. A portion of this was comprised of previous pericranium which had been used for dural repair. I was able to identify the junction of the tumor capsule and the frontal lobe cortex. Working superiorly and laterally around the tumor, I was able to easily dissect the tumor capsule from the brain parenchyma. There was no pial plane remaining. I then worked medially and inferiorly, detaching the tumor capsule from the medial wall of superior sagittal sinus. I worked inferiorly, detaching the tumor capsule from the thickened dura of the orbital roof. The tumor appeared to invade the orbital roof. I then circumferentially dissected the remaining tumor capsule off the deep brain parenchyma while utilizing the operative microscope. I was able to inspect anterior and medial. The olfactory bulb and olfactory nerve remained intact. I then sharply dissected some remaining bits of tumor capsule from the medial wall of the superior sagittal sinus, oversewing it with a Nurolon suture in several places. I then elevated the dura off the orbital roof and excised it. At this time, looking circumferentially, we had performed a gross total resection of the intracranial component of the tumor. A piece of Dura-Guard dural substitute was sutured in a watertight fashion to the dural edges including the medial superior sagittal sinus and inferiorly along the remaining orbital roof dura.
At this time, Dr. Meyers performed the frontal sinus extirpation and removed the right orbital roof and intraorbital tumor and will dictate that in a separate note. I returned to the procedure when he was completing the frontal sinus procedure and excised the fat graft from the right thigh. This wound was closed with interrupted 3-0 Vicryl suture in the dermis and staples. A drain was placed.
The vascularized flap was onlaid over the bilateral frontal ostia which had been plugged with muscle. This was then onlaid over the orbital roof and placed beneath the suture line of the orbital dura and duraplasty suture line. The fat segments were then placed on top of the vascularized graft into the frontal sinus cavity. Tisseel fibrin glue was irrigated over the frontal dura and over the vascularized graft. Epidural hemostasis was ensured with bipolar cautery. The Medpor plate was then slightly reduced and cut so that it fit the defect. We made sure to ensure that there was ample room between the cranioplasty plate and the brow to ensure the vascular graft would not be compromised. The cranioplasty plate was secured in place with several Stryker miniplates. A small Hemovac drain was brought through a separate stab incision. The galea was reapproximated with 2-0 Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well. He was transported to the surgical intensive care unit. He will remain intubated overnight.
Ear/Nose and Throat surgeon report
Procedure: 1. Coronal approach to anterior skull base 2. Cranialization of frontal sinuses 3. Transcranial exploration of right orbit with tumor removal 4. Pericranial flap with closure of CSF leak 5. Cranioplasty larger than 5 cm
Specimen: Intracranial mass, right orbital contents, dural margin
Estimated Blood Loss: 1100 ml
Indications for Procedure: The patient has a history of right frontal meningioma excised 2 years ago. Pathology was consistent with atypical meningioma. Surveillance imaging demonstrated recurrence.
Operative Findings: Large recurrent tumor involving the right frontal lobe, anterior and posterior tables of the right frontal sinus, right forehead soft tissues and right orbit.
Description of Procedure: The patient and his family were met in the preoperative area. Risks, benefits and alternatives of procedure were discussed and the patient and family wished to proceed patient was brought to the operating room and a lumbar drain and arterial line were placed. Patient was placed supine operative table and general anesthesia was induced via endotracheal tube. Dr. Wills place patient in a Mayfield headholder. The cranium and the right thigh were prepped and draped in the usual sterile fashion. A timeout was performed identifying the patient and the procedure. Patient's previous craniotomy incision was marked and injected with approximately 10 mL 1% lidocaine with 1 100,000 epinephrine. 10 blade was used to open the previous craniotomy incision and identify subgaleal supra-paricranial plane. In the left frontal region there was a robust and intact pericranial layer. Working his subgaleal plane the scalp flap was elevated. Once the region of the tumor extension through the previous craniotomy site was encountered the plane was switched to a supra-galeal plane within the substance of the frontalis muscle. A very small amount of frontalis muscle was left adherent to the tumor as the flap was elevated. Once the area of the tumor was passed a subgaleal plane was again established. The flap was elevated to the level of the superior orbital rims. The pericranial flap was then elevated. This was harvested in an L-shaped fashion taking some of the remnant pericranium superior to the tumor site on the right and involving the entire pericranial flap on the left. The flap was carefully elevated was then pedicled on the supratrochlear and supraorbital vascular bundles. Flap was carefully covered with moist gauze and kept moist throughout the entire case. Dr. Wills then proceeded with removing the previous hardware closing the craniotomy site and opening craniotomy. He then proceeded to enlarge the craniotomy site which involved both the right and left frontal sinuses. The posterior table of the left frontal sinus was not violated. He then proceeded to resect the intracranial portion of the tumor and repair of the dural defect. Following his removal intracranial portion of the tumor I proceeded to carefully remove all the mucosa from both frontal sinuses down into the frontal ostium and then the frontal recess and remove the posterior table the right frontal sinus. The intersinus septum was also removed. The posterior table of the left frontal sinus was left intact. The entire bony surface of the remaining walls of the frontal sinuses were drilled with a diamond bur to ensure no rests of mucosal tissue. There was evidence of thickening of the bone of the right orbital roof. This bone was soft and had evidence of tumor involvement. The involved bone of the right orbital roof was removed using a combination of Kerrison and Roger forceps. The periorbita was left intact. The bone was separated back to healthy bone. The vault of bone and tumor peeled away from the periorbita without difficulty and there was no evidence of invasion of the periorbita. Temporalis muscle was harvested from the deep surface of the right temporalis muscle. This muscle was then packed into the frontal recess bilaterally. The right orbital roof was reconstructed using a 0.3 mm titanium plate. This was trimmed to size and was secured into position with two 4 mm screws anteriorly into the posterior surface of the anterior table of the frontal sinus and one screw laterally. Dr. Wills harvested fat from the right thigh. No fascia lata was harvested. The previously planned Medpor implant was then trimmed to size to fit the craniotomy defect following tumor removal. The defect was larger than 5 cm. Care was taken to ensure that there was a wide enough opening inferiorly along the frontal bar to allow for the pericranial flap to drape into the sinus without restriction with extra space plan for any swelling of the flap. The pericranial flap was then laid over the frontal ostium bilaterally, draped over the right orbital roof and was tucked under the inferior dura along the floor of the anterior cranial fossa. There was a small CSF leak from the dura along the floor of the anterior cranial fossa which was addressed by laying the pericranial flap under the dura along the skull base and securing it posteirorly. The previously harvested fat was placed within the left frontal sinus and overlying the pericranial flap in the region of the frontal ostia. Tissue glue was then used to cover the dural repair in addition to the edges of the pericranial flap. The Medpor implant was secured into place using titanium mini plates and screws. The opening for the pericranial flap was again assessed and there was no evidence of restriction with all on the flap. Dr. Wilson placed a subgaleal drain. The coronal incision was closed in 2 layers, first with interrupted buried Vicryl sutures in the galeal layer followed by staples and the skin. Patient tolerated the procedure without immediate complication. The patient was transferred to the intensive care unit in stable condition.
Neurosurgeon op report
NAME OF PROCEDURE:
1. Bilateral revision redo frontal craniectomy for resection of recurrent atypical meningioma.
2. Bilateral frontal sinus extirpation.
3. Right leg fat graft.
4. Bifrontal cranioplasty with Medpor synthetic plate.
DESCRIPTION OF PROCEDURE:
Preoperatively, the patient had an MRI scan and CT scan performed. The MRI was performed with BrainLAB protocol. This showed a significant growth of the tumor since his previous scan of early December. The intracranial portion of the tumor had previously measured 2.5 cm in diameter. It now measured over 5 cm in diameter. There was deep extension into the right frontal lobe. Preoperatively, the patient had no new complaints, but his wife noted some short-term memory difficulty.
After the patient was brought to the operating room, he was anesthetized. His head was affixed in a Mayfield head holder. The head of the bed was brought up 20 degrees and the head positioned with the neck flexed and chin extended. The Mayfield was secured to the table. BrainLAB neuronavigation was registered to the patient's facial features with good accuracy. The scalp and face were then clipped, prepped, and draped in the usual sterile fashion. Dr. Meyers and I performed the exposure; 10 mL of 1% lidocaine with epinephrine was infiltrated into the skin. A bicoronal skin incision was performed utilizing his previous incision. We were able to identify pericranium and developed a plane between the galea and the pericranium reflecting the scalp anteriorly. Previously, I had employed an interfascial approach, which was revised. Both orbital rims were exposed, as was the nasion. Dr. Meyers was then able to elevate the vascularized pericranial flap. The extracranial extension of the tumor was palpable and visible. The scalp had been dissected off this extracranial extension of the tumor in a plane which appeared to be the right frontalis muscle.
Once the scalp had been reflected anteriorly and maintained in place with fishhook retractors, bipolar cautery was used to maintain hemostasis. Cautery was used to delineate the pericranium from the skull at the circular area of the external extension. Previous craniotomy cuts were identified. The previous bur-hole covers were removed. The previous right frontal craniotomy was revised with the osteotome and elevated atraumatically. The frontal sagittal sinus was re-exposed. There was additional frontal bone in the bone of the frontal sinuses which was extending around the tumor which invaded frontal bone. This was delineated from the dura circumferentially with the drill. The anterior wall of the frontal sinus was then removed with the drill. The posterior wall of the frontal sinus lip was left intact. The outer calvaria of the left frontal bone was removed with the drill to accommodate the patient's preformed cranioplasty plate.
Once all bone had been removed circumferentially from around the tumor where it protruded from the dura, I entered the tumor with an 11-blade knife and removed a piece and sent this to the pathologist who confirmed meningioma. The tumor was then debulked internally using the Sonopet ultrasonic aspirator. The tumor itself was soft and easily evacuated. When I had circumferentially and deeply evacuated the internal components of the tumor, additional specimens were sent from the deep portion of the tumor. I then opened the dura superior and lateral to the tumor. A portion of this was comprised of previous pericranium which had been used for dural repair. I was able to identify the junction of the tumor capsule and the frontal lobe cortex. Working superiorly and laterally around the tumor, I was able to easily dissect the tumor capsule from the brain parenchyma. There was no pial plane remaining. I then worked medially and inferiorly, detaching the tumor capsule from the medial wall of superior sagittal sinus. I worked inferiorly, detaching the tumor capsule from the thickened dura of the orbital roof. The tumor appeared to invade the orbital roof. I then circumferentially dissected the remaining tumor capsule off the deep brain parenchyma while utilizing the operative microscope. I was able to inspect anterior and medial. The olfactory bulb and olfactory nerve remained intact. I then sharply dissected some remaining bits of tumor capsule from the medial wall of the superior sagittal sinus, oversewing it with a Nurolon suture in several places. I then elevated the dura off the orbital roof and excised it. At this time, looking circumferentially, we had performed a gross total resection of the intracranial component of the tumor. A piece of Dura-Guard dural substitute was sutured in a watertight fashion to the dural edges including the medial superior sagittal sinus and inferiorly along the remaining orbital roof dura.
At this time, Dr. Meyers performed the frontal sinus extirpation and removed the right orbital roof and intraorbital tumor and will dictate that in a separate note. I returned to the procedure when he was completing the frontal sinus procedure and excised the fat graft from the right thigh. This wound was closed with interrupted 3-0 Vicryl suture in the dermis and staples. A drain was placed.
The vascularized flap was onlaid over the bilateral frontal ostia which had been plugged with muscle. This was then onlaid over the orbital roof and placed beneath the suture line of the orbital dura and duraplasty suture line. The fat segments were then placed on top of the vascularized graft into the frontal sinus cavity. Tisseel fibrin glue was irrigated over the frontal dura and over the vascularized graft. Epidural hemostasis was ensured with bipolar cautery. The Medpor plate was then slightly reduced and cut so that it fit the defect. We made sure to ensure that there was ample room between the cranioplasty plate and the brow to ensure the vascular graft would not be compromised. The cranioplasty plate was secured in place with several Stryker miniplates. A small Hemovac drain was brought through a separate stab incision. The galea was reapproximated with 2-0 Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well. He was transported to the surgical intensive care unit. He will remain intubated overnight.