sbrow043
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Would this be an unlisted code 43659 and if so what code would I compare it to?
Preoperative diagnosis: perigastric cyst
Postoperative diagnosis: perigastric cyst
Procedure: Robotic-assisted resection of perigastric cystic mass with en bloc partial gastrectomy and left colectomy
Specimen: perigastric cystic mass with partial gastrectomy and left colectomy
Indications: This is a 58 year old female with a history of a large perigastric cystic mass. She has undergone biopsy as well as endoscopic stent drainage of the cyst. All biopsies have been benign, although the cyst wall is thick on CT and concerning for a malignancy of some kind. Resection was recommended. The risks and benefits were explained. This includes the risk of bleeding, infection, conversion to open procedure, and the low possibility of intraoperative or perioperative death. After answering all questions the patient elected to proceed.
Operative findings: the lesion was densely adhesed to the wall of the stomach as well as the mesentery of the splenic flexure of the colon.
Procedure description: After the administration of preoperative antibiotics the patient was taken to the operating room placed in the supine position and a general anesthetic was inducted. Following this the patient's abdomen was prepped and draped in the standard sterile fashion. A final timeout confirmed the correct patient and procedure.
A supra-umbilical incision was made and access to the abdominal cavity was gained using open Hassan technique. Under direct visualization 3 additional robotic ports were placed across the mid abdomen. An assistant port was also placed in the lower abdomen. The robot was docked and I left the patient side to approach the robotic console.
The cystic mass was visible off of the greater curve of the stomach. Dissection was begun by opening the gastrocolic ligament distal to the mass in order to expose the posterior wall of the stomach. This revealed no evidence of invasion into the pancreas. Dissection through the gastrocolic ligament became difficult and there was evidence that the cyst was densely adhesed to the mesentery of the splenic flexure of the colon. The colon itself did not appear to be involved. Attempts were made to dissect the cyst off of the mesentery but this proved difficult and there was concern that the cyst would be entered and leak contents in the abdomen. The decision was made to remove the splenic flexure of the colon along with the involved mesentery.
The left colon was mobilized laterally by taking down the white line of Toldt. The splenic flexure was mobilized out of the left upper quadrant. The distal transverse colon and proximal descending colon were transected with the robotic stapler. The mesentery of the splenic flexure of the colon was transected below the level of involvement with the cyst to perform an en bloc resection of both structures.
Attention was then turned to the cyst involvement with the stomach. As much of the greater curve omentum was mobilized as possible. There remained approximately 10 cm of involvement of the greater curve with the cyst. I did not feel that this portion of stomach could be safely wedged out with a stapler and avoid undue narrowing of the body of the stomach. To avoid this a gastrotomy was made distally on the anterior wall of the greater curve and the portion of the wall of the stomach involved with the cyst was wedged out using the robotic vessel sealer. This included the endoscopic stent. The remaining retroperitoneal attachments to the cyst were dissected and the entire specimen was placed in a bag for retrieval.
Reconstruction was begun by first anastomosing the colon. A side-to-side functional end-to-end stapled anastomosis was performed with the robotic stapler. The final colotomy was closed in 2 layers with 3-0 running barbed suture and interrupted 3-0 Vicryl suture. Attention was then turned to the gastrotomy. The gastrotomy was longitudinal along the greater curve. I elected to close this transversely to avoid narrowing the body of the stomach. This was closed in 2 layers with running 2-0 PDS barbed suture and interrupted 3-0 Vicryl suture. Prior to closure a nasogastric tube was placed distally in the antrum. Once the stomach and colon had been reconstructed hemostasis was confirmed throughout the left upper quadrant. Pneumoperitoneum was evacuated and all ports removed. The supraumbilical port site had been used as the extraction site. The fascia was closed with #1 PDS barbed suture. The skin of all incisions were closed with 4-0 monocryl suture. The patient was awoken and taken to recovery in stable condition. At the end of the procedure all counts were correct.
Disposition: Stable to recovery
Preoperative diagnosis: perigastric cyst
Postoperative diagnosis: perigastric cyst
Procedure: Robotic-assisted resection of perigastric cystic mass with en bloc partial gastrectomy and left colectomy
Specimen: perigastric cystic mass with partial gastrectomy and left colectomy
Indications: This is a 58 year old female with a history of a large perigastric cystic mass. She has undergone biopsy as well as endoscopic stent drainage of the cyst. All biopsies have been benign, although the cyst wall is thick on CT and concerning for a malignancy of some kind. Resection was recommended. The risks and benefits were explained. This includes the risk of bleeding, infection, conversion to open procedure, and the low possibility of intraoperative or perioperative death. After answering all questions the patient elected to proceed.
Operative findings: the lesion was densely adhesed to the wall of the stomach as well as the mesentery of the splenic flexure of the colon.
Procedure description: After the administration of preoperative antibiotics the patient was taken to the operating room placed in the supine position and a general anesthetic was inducted. Following this the patient's abdomen was prepped and draped in the standard sterile fashion. A final timeout confirmed the correct patient and procedure.
A supra-umbilical incision was made and access to the abdominal cavity was gained using open Hassan technique. Under direct visualization 3 additional robotic ports were placed across the mid abdomen. An assistant port was also placed in the lower abdomen. The robot was docked and I left the patient side to approach the robotic console.
The cystic mass was visible off of the greater curve of the stomach. Dissection was begun by opening the gastrocolic ligament distal to the mass in order to expose the posterior wall of the stomach. This revealed no evidence of invasion into the pancreas. Dissection through the gastrocolic ligament became difficult and there was evidence that the cyst was densely adhesed to the mesentery of the splenic flexure of the colon. The colon itself did not appear to be involved. Attempts were made to dissect the cyst off of the mesentery but this proved difficult and there was concern that the cyst would be entered and leak contents in the abdomen. The decision was made to remove the splenic flexure of the colon along with the involved mesentery.
The left colon was mobilized laterally by taking down the white line of Toldt. The splenic flexure was mobilized out of the left upper quadrant. The distal transverse colon and proximal descending colon were transected with the robotic stapler. The mesentery of the splenic flexure of the colon was transected below the level of involvement with the cyst to perform an en bloc resection of both structures.
Attention was then turned to the cyst involvement with the stomach. As much of the greater curve omentum was mobilized as possible. There remained approximately 10 cm of involvement of the greater curve with the cyst. I did not feel that this portion of stomach could be safely wedged out with a stapler and avoid undue narrowing of the body of the stomach. To avoid this a gastrotomy was made distally on the anterior wall of the greater curve and the portion of the wall of the stomach involved with the cyst was wedged out using the robotic vessel sealer. This included the endoscopic stent. The remaining retroperitoneal attachments to the cyst were dissected and the entire specimen was placed in a bag for retrieval.
Reconstruction was begun by first anastomosing the colon. A side-to-side functional end-to-end stapled anastomosis was performed with the robotic stapler. The final colotomy was closed in 2 layers with 3-0 running barbed suture and interrupted 3-0 Vicryl suture. Attention was then turned to the gastrotomy. The gastrotomy was longitudinal along the greater curve. I elected to close this transversely to avoid narrowing the body of the stomach. This was closed in 2 layers with running 2-0 PDS barbed suture and interrupted 3-0 Vicryl suture. Prior to closure a nasogastric tube was placed distally in the antrum. Once the stomach and colon had been reconstructed hemostasis was confirmed throughout the left upper quadrant. Pneumoperitoneum was evacuated and all ports removed. The supraumbilical port site had been used as the extraction site. The fascia was closed with #1 PDS barbed suture. The skin of all incisions were closed with 4-0 monocryl suture. The patient was awoken and taken to recovery in stable condition. At the end of the procedure all counts were correct.
Disposition: Stable to recovery
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