Left lower lobectomy with bronchial / muscle flap repair

rgeib

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Looking for some advice on the following op report:

SALIENT OPERATIVE FINDINGS:
Bronchoscopy revealed tumor extending out of superior segment of
the lower lobe, but it did not protrude as high as the upper lobe.
We performed a VATS procedure. I was concerned that there would be
tumor spill. After some dissection with the VATS, we felt that
there would be potential for tumor spell and therefore we abandoned
this and went through the thoracotomy. At that point in time, we
divided all the vessels. We removed anterior 11 nodes in station
which are by frozen section negative. We also removed station 8
nodes and posterior 11 nodes and station 7 node #1 and station 7
node #2. However, when we came to divide the bronchus and the
bronchus staples, we noticed that the tumor was pushed up and I believe that the compression of the bronchus stapler caused the
nearest of the tumor to push into the margin we were to staple.
For this reason, I felt it appropriate not to do this and instrument I performed an open bronchotomy and I had
taken down an intercostal muscle flap in the fifth space, and I used
this to bolster my repair.
Estimated blood loss was 175 mL.

OPERATIVE NOTE:
The patient was brought to the operating room, underwent general
anesthesia, and single-lumen endotracheal intubation. A time-out
and a safety pause were then performed conforming to universal
protocol. The bronchoscope was then passed down the endotracheal
tube. We fully visualized all of the tracheobronchial tree. On the
right side, there were only 2 segments to the right upper lobe.
Bronchus intermedius was normal as was the lower lobe and middle
lobe. Primary carina was sharp.

Following that, we then passed the bronchoscope down the
endotracheal tube and into the airway. We could see the
secondary carina that was also sharp. Left upper lobe was normal.
There was an endobronchial tumor protruding out of the superior
segment to the right of the left lower lobe, but it was not so
large. It did not extend up to the area of the secondary
carina, but ended just distal to the secondary carina. This is
entirely compatible with endobronchial polypoid carcinoid tumor.
I felt we would be able to remove this with a lobectomy or
potentially even with superior segmentectomy.

Following that, we then removed the bronchoscope. We changed over
to a double-lumen tube. After this was done, we then turned the
patient, prepped and draped the chest in a normal fashion, and then
performed eighth intercostal space port incision. Through this, we
passed the thoracoscope and then in the fifth intercostal space, we
created an incision and accessed incision through these as well as
the fifth posterior port site, we started to take down the lung. We
identified anterior 11 nodes which were sent for frozen section, and
were negative. We could see that there was some bulk disease in the
superior segment of the lower lobe; however, due to compression
August tumor I was concerned about possible breaches of the pleura,
and subsequent tumor spill, therefore we then converted to an open
thoracotomy.

We then went to fifth intercostal serratus sparing posterolateral
thoracotomy, we took down the fifth intercostal bundle as a
vascularized pedicle. This was then kept for subsequent repair.
After this was done,and after we had entered the chest we then
mobilized the pulmonary artery and divided it with the endovascular
stapler. We did identify posterior 11 nodes as well as station 7
nodes 1 and 2. They were sent for frozen section and were negative
for tumor.

After that was
1done, we then divided the inferior pulmonary vein after confirming
that we had not impaired the venous drainage of the superior pulmonary vein, that we did this. We then came to the bronchus, we
passed the bronchus stapler across the left lower lobe bronchus
after removing all nodes from around the bronchus, but compression
of this caused tumor to peep up and we stapled tumor into our
bronchus margin. I, therefore, then stopped, took the staples off
and then performed an open bronchotomy. This way, we had adequate
margin as assessed by frozen section and this did look like a
carcinoid tumor or neuroendocrine tumor. After that was done, we
then repaired the bronchus with an interrupted 4-0 PDS sutures. We
also then placed our intercostal muscle flap on the bronchus stump
to bolster the repair.
There was no air leak thereafter. We
irrigated out the chest with water to lyse any cells. We then
inserted 2 On-Q catheters for postop drainage. We placed a buried
24-French chest tube through the port site. We then closed the
chest with #1 PDS figure-of-eight pericostal sutures, #1 PDS to the
muscle layers, 2-0 Vicryl to the subcutaneous tissue, and 4-0
Monocryl and Dermabond to the skin.
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-The areas in bold are where I'm getting hung up. The use of an intercostal muscle flap suggests I should use 15734 in addition to my lobectomy code (32480). However, I'm wondering if 32501 is also warranted here? CPT guidelines for 32501 state it is "to be used when a portion of the bronchus to preserved lung is removed and requires plastic closure to preserve function of that lung. It is not to be used for closure of the proximal end of a resected bronchus." I'm not sure if just the closure is what is being described here? Would this just be included in 32480? Any help would be appreciated. Thanks in advance. (P.S., I do know that I also have to add 38746 for the mediastinal lymph node dissections)
 

dvance4210

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You might want to look at 32486....which is the lobectomy with resection of segment of the bronchus... From what I'm reading that sounds more appropriate but I would query your physician if possible. It sounds like a "sleeve lobectomy" but I could be off base. Add the muscle flap (15734) and mediastinal lymph node resection (38746) like you stated.

D. Vance, CPC, CCVTC
 
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