Op note - open vs lap

Cmama12

Guru
Messages
176
Best answers
1
I code OB/GYN including GYN/ONC and these surgeries often involve general surgeons. In this case it was a co-surgery, so I had to coordinate with Gen Surg coding for the codes. This particular Gen Surg dr puts in his cpt codes in the procedure description. (changed to lap/unlisted for the two in blue) My question is for the portion highlighted in orange. How would someone know this particular portion of the procedure was open, and not also laparoscopic? Is it the "paddle of skin"? ( I put both notes in for comparison.)


Gen Surg note
PREOP DIAGNOSIS: Presacral pelvic tumor midline to left lateral H/O Granulosa cell tumor

POSTOP DIAGNOSIS: SAME

PROCEDURE:
LAPAROSCOPIC EXCISION PRESACRAL TUMOR/MASS CPT 49215-62
Gynecologic Tumor debulking Laparoscopic CPT 58957-62

Excision Abdomen wall malignant tumor < 5 cm CPT 22904-62

PROCEDURE:

The patient was taken to the operating suite placed in a supine position after general anesthesia induced placed in yellowfin leg stirrups with meticulous attention to padding all pressure points. SCDs and Ted's used for DVT prophylaxis. Intravenous antibiotics administered. Patient identification and time-out performed by all of the operating room staff. Patient was prepped and draped in a sterile fashion. We worked as co-surgeons during the case as there was simultaneous involvement of both colorectal and gynecologic structures. Optiview entry at the left hemi abdomen with eventual placement of 8mm Robotic ports x 4 and an assist port all under direct vision. The small bowel was packed in the upper abdomen and the left colon completely we mobilized meticulously avoiding injury to the vascularity as this had already been previously mobilized. The ureters were identified and injury spared. We dissected into the pre sacral space all the way down to the mid pelvis from the left side. Meticulous dissection was needed in this hostile area to avoid injury to the left lateral rectum. The mass was extraperitoneal and carefully dissected off the left side wall and presacral fascia This area and a more distal area was further excised sending for permanent section. I then performed a flexible sigmoidoscopy to confirm that the rectum had not been injured the mucosa was intact there was no evidence of any injury extending externally or internally. The rectum was distended tightly with air with saline filling the pelvis and the proximal bowel clamped with no air leak noted. We then addressed numerous intra peritoneal masses ranging from mm to several cm excising with attached peritoneum to grossly negative margins and sending as right and left lateral side wall tumors. The ureters were intimate with these lesions and required special care to dissect free. The right lower quadrant abdomen wall recurrence was excised from the skin down taking a paddle of skin and the entire localized lesion with electrocaturey including attached abdomen wall. The abdomen wall was not repaired as it involved the anterior muscle fascial layer only. The subcutaneous tissue closed with 3-0 Vicryl and the skin with running 4-0 Monocryl. The abdomen was irrigated with Irrisept. The ports removed under direct vision the assist port closed with a Gray stick 0 Vicryl followed by running subcuticular 4-0 Monocryl for the skin the wounds were dressed sterilely the patient options well there were no complications blood loss was minimal. Patient was extubated transferred recovery room in stable condition sponge needle and instrument counts were correct.


GYN ONC note

PREOPERATIVE DIAGNOSIS:
Perirectal mass and anterior abdominal wall mass, less than 5 cm, worrisome for recurrent granulosa cell tumor with increasing inhibin B.

POSTOPERATIVE DIAGNOSIS:
Perirectal mass and anterior abdominal wall mass, less than 5 cm, worrisome for recurrent granulosa cell tumor with increasing inhibin B.

PROCEDURE:
1. Diagnostic laparoscopy followed by robotic tumor debulking including radical peritoneal stripping bilaterally for gross tumor along the peritoneal surfaces with confirmation after frozen diagnosis for a recurrent granulosa cell tumor. This was a robotic procedure in a recurrent setting and should be billed accordingly with a robotic code.
2. Removal of less than 5 cm portion of anterior abdominal wall for malignant tumor resection in the anterior abdominal wall after needle/wire localization by Interventional Radiology.
3. Resection of presacral fluid collection and mass, likely consistent also with recurrent tumor performed as a co-surgeon operation with Dr. xx. It should be noted that this entire operation was performed in concert with Dr. xx and this was a co-surgeon operation given the intimacy of the aforementioned masses with the rectum. Please make a note of it.


FINDINGS:
Upon entrance into the abdomen unfortunately there was clear evidence of tumor. A portion was taken and sent to frozen and this came back. The diaphragmatic surface of the liver capsule, splenic capsule and pericolic gutters were without any evidence of tumor. We ran the bowel robotically and there was no evidence of tumor. The mesenteric surfaces were without evidence of tumor. The tumor seemed to be consolidated in the pelvis. You could easily identify a fluid collection that was identified on CT imaging to the left of the rectosigmoid. There almost was a presacral collection and mass. This mass was biopsied and this is what the frozen was sent off as which came back recurrent GCT. There was tumor along the left pelvic sidewall and right pelvic sidewall. They seemed to be isolated areas though and all about anywhere from 2-3 cm. The bladder peritoneum was without any evidence of tumor. The vaginal area was without any evidence of tumor. The tumor seemed to be consolidated beneath the pelvic brim and was removed in its entirety after radical peritoneal stripping and standard debulking. At the conclusion of the case we did send off some ascites that was concerning, but there was no evidence of disease whatsoever. So, at least she is microscopic in terms of residual. The anterior abdominal wall was easily localized with the wire and this area was resected with about 2-3 cm margins. An area was identified that to me looked like recurrent disease. This is likely a port recurrence. This area was repaired in a primary fashion.

SPECIMENS:
Multiple including perirectal/presacral mass, left pelvic sidewall, right pelvic sidewall, ascites and anterior abdominal wall 1, 2 and 3.


TECHNIQUE:
After informed consent was obtained, the patient was identified as xxx. Anesthesia was delivered. Her MR number was confirmed as xxx. General anesthetic was applied. Exam under anesthesia revealed the aforementioned findings. Diagnostic laparoscopy was performed through an Optiview entry technique in a pass x1 in left upper quadrant, x4 ports then placed under visualization. The 5 was switched out to the 8. The aforementioned findings were noted. We realized that we could do this robotically on that all the masses that were identified and there were more than we thought we had from the start based on CT imaging. However, these were small enough that we felt that they could easily be removed via the EndoCatch bag which we accomplished. I started off by identifying the ureters on both sides, developing the perirectal space and performing radical peritoneal stripping all along the right side, removing everything that I thought had tumor on it. I then biopsied the perirectal/presacral mass, just the tip of it, that was to the left of the rectum and seemed to abut this fluid collection which was a bit atypical. The mass came back recurrent GCT and then Dr.xxx was kind enough to move forward and remove this presacral/perirectal mass which was somewhat intimate with the rectum. Please refer to his notes for details. He continued by removing tumor along the left pelvic sidewall, not dissimilar to what had been accomplished on the right. Once this was completed we evaluated the rest of the abdomen. There was no evidence of any other tumor. We then moved forward with the anterior abdominal wall resection. Drawing an elliptical area about 2 cm around the wire I simply made an incision and then dissected bluntly so that I had 2 cm margins all the way around the wire. I then resected this all the way down to the fascial layer and a portion of the fascia was removed. The first portion was sent off as anterior abdominal wall 1. Then I could see that the wire was going into what appeared to me to be frank tumor. I resected this area as well with 1-2 cm margins and this was sent off as abdominal wall 2 and then I continued 1 more resection to make sure negative margins were obtained and this was sent off as abdominal wall 3. Once this was completed the defect was repaired in a standard fashion. The whole area measured notably less than 5 cm of resection. Once this was completed the area was copiously irrigated. All was noted to be hemostatic. A TAP block was used for local anesthetic. The abdomen was desufflated and the skin edges approximated per protocol. The patient seemed to tolerate the procedure very well. She will be awakened per Anesthesia. Please refer to Dr. xxx's notes for details.
 

csperoni

True Blue
Messages
1,473
Location
Selden
Best answers
3
For me, the real key that would tell me that abdominal wall excision was not laparoscopic is "from the skin down". The skin paddle is another clue, but a smaller one.
The gynonc note clearly has more detail than the gen surg note. "Drawing an elliptical area.....made and incision and then dissected......resected down to fascial layer..."

Thank you for posting. I code only for gynonc, and appreciate seeing procedures that I don't see by my providers, or that my providers do differently.
 
Top