Wiki Minimally invasive endoscopic endocardial Maze


Weston, FL
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Chronic atrial fibrillation. 427.31

Minimally invasive endoscopic endocardial Maze. 33265
Briefly, patient identified in the holding area of the cath lab,
placing her on the table in the supine position. Preoperative
sedation of IV antibiotics was given to the patient. All the
appropriate monitors were placed. At this point, endotracheal tube
general anesthesia was given to the patient. A Foley catheter was
inserted. A right radial A-line was placed and a right internal
jugular introducer was placed. A transesophageal echocardiogram was
performed that showed no evidence of any mitral valve pathology, as
well as no evidence of any clot in the left atrium. So, at this
point, we proceeded with the epicardial portion of the hybrid Maze,
utilizing a minimally invasive technique. A midline incision was
created, about 1.5 cm below the xiphoid process. The incision was
approximately 1.5 cm. We were able to enter through the subcutaneous
tissue with the Bovie cautery, achieving hemostasis. At this point,
the peritoneal cavity was able to be entered and once entering into
the peritoneal cavity, over my index finger, two 5 mm ports were
inserted in the midclavicular line, one in the left side and one on
the right, in the periumbilical region. At this point, the 12 mm
trocar was inserted into the initial peritoneal incision made at the
subxiphoid level. At this point, CO2 was infused to a
pneumoperitoneum of 12 mmHg. At this point, with the patient in the
reverse Trendelenburg position, using a 0 degree 10 mm scope, we were
able to identify the central portion of the diaphragm right just the
left lobe of the liver, and using an endoscopic scissors with
endoscopic forceps we were able to create a 1.5 cm incision in the
central portion of the diaphragm right over the left lobe of the
liver. Once entering into the diaphragmatic recess, we were able to
enter into the pericardial well, and once entering into the
pericardial sac, we were able to identify the cardiac structures. At
this point, the 12 mm trocar was removed and the _______ cannula was
inserted and cautiously placed into the posterior pericardial well,
elevating the cardiac structures and thus identifying the posterior
aspect of the left atrium using a 10 mm scope. At this point, the
entire left atrial body was able to be identified as well as the take
off of the pulmonary veins, both right and left, and using a _______
3 cm unilateral epicardial RF ablation device, we were able to create
transmural lesions, divide the entire left atrium, isolating the
entire left atrium and the pulmonary veins from the entire cardiac
structures. This was done without any difficulty. Once all the
lesions were created and checked for completeness, and also crossed,
we were able to pass our cannula over the IVC to the transverse
sinus, all the way anteriorly towards the anterior, superior, and
inferior pulmonary veins on the right, and the lesions were created
also in this area from the transverse sinus all the way to the
oblique sinus. After these lesions had been created, this isolating
the right pulmonary veins more anteriorly, we were able to pass the
cannula once again under the cardiac structures, and pass them to the
anterior portion of the left pulmonary veins, where this was created.
The lesion patterns were created similarly to the right side. This
was seminating from the ligament of _______ all the way down to the
inferior pulmonary vein on the left side. At this point, once all
the lesions had been completed and the patient remained
hemodynamically stable, a 24-French Blake drain was inserted into the
pericardial wall, and emanating through one of the 5 mm ports and
secured with an Ethibond suture. At this point, the cannula was
removed and CO2 was diffused, and the midline incision was closed
with interrupted figure-of-eight sutures, encompassing both the
anterior and posterior rectus sheath, as well as the peritoneum.
Once the fascia was then closed using 2-0 Vicryl suture and 3-0
Monocryl at the skin, the other 5 mm port was closed with a 2-0
Vicryl suture and Monocryl. The patient tolerated this part of the
procedure well. The chest tube was connected to a Pleur-evac and -20
cm of vacuum. At this point, the patient was heparinized. There was
no evidence of bleeding. Dr. was called in to perform the
endoscopic portion of the procedure, as well as performing an
endocardial mapping. The patient remained hemodynamically stable and
tolerated this portion of the procedure well. Please see Dr.
dictation for the remainder of the procedure.

Can some one please help me with this report. I think I have the right code
Please correct me if I'm missing something but as I read through this note I'm not seeing that this procedure was done with an endoscope so wouldn't use the 33265. There was a definite midline incision made and then additional trocars were inserted for assistance with the devices. This should be billed as an open Maze procedure with 33255. If done along with another cardiac procedure, then use the add-on code 33258.

Hope this helps!