Question Parathyroidectomy with transcervical thymectomy


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Hello Everyone,
In the following encounter, Is thymectomy inclusive of Parathyroidectomy
I'm coming up with CPT:60500(parathyroidectomy) and 60520 which is thymectomy(separate procedure)
Any suggestions?

1. Parathyroidectomy with 4-gland exploration.
2. Transcervical thymectomy.
3. Excision of level 6 lymph nodes
Primary hyperparathyroidism.
1. Level 6 lymph nodes.
2. Anterior thymus.
3. Biopsy of right thyroid nodule.
1. Normal-appearing left superior parathyroid gland. Enlarged lymph nodes
in level 6 of the neck.
2. Normal-appearing thymus gland.
3. No apparent evidence of parathyroid adenoma.
The patient was identified in the preoperative holding area and brought back
to the operating room and was placed supine on the operating table. General
endotracheal anesthesia was induced by the Anesthesia Service without any
complications with a 7.0 NIM tube for recurrent laryngeal nerve monitoring. A
shoulder roll was placed for mild neck extension to allow better exposure of
the cervical portion of the neck. The neck was then prepped and draped in
usual sterile fashion. After correct patient and procedure verification, we
began by making a 4 cm Kocher incision in the natural skin fold just
approximately 2 fingerbreadths above the sternal notch. This was deepened to
the skin using Bovie cautery down to the subcutaneous tissue and the platysma
muscle until the median raphae was encountered. The median raphae was then
opened and subsequently, the superior and inferior subplatysmal flaps were
created to allow better exposure. We then proceeded to open up the raphae
inferiorly toward the sternal notch and superiorly towards the thyroid
cartilage. The thyroid muscles were then peeled away off the thyroid using
gentle blunt and sharp dissection with a combination of manual retraction and
Bovie cautery. We began on the right side of the neck as the ultrasound
performed in the clinic was suggestive of an inferior right parathyroid gland.
After careful inspection of the right inferior neck, there appeared to be no
evidence of parathyroid gland and as such, we moved our attention to the
superior pole, which was gently mobilized. We were also unable to find the
superior gland in this location. We then considered to dissect in the carotid
sheath and identified the vagus nerve, which was intact. We then further
dissected down inferiorly around the area of the recurrent laryngeal nerve and
level 6 lymph nodes, which appeared enlarged, but did not appear to have any
evidence of enlarged parathyroid gland. The level 6 lymph nodes of the right
neck were then carefully resected and passed off the field as a specimen. We
did find what appeared to be an indurated nodule, which was a questionable
parathyroid gland. This was sent off for frozen section. Pathology returned
back as part of the thyroid gland. We then moved our attention to the left
side of the neck for exploration as we did not find tissue suggestive of a
parathyroid adenoma. We began inferiorly on the left side in close
approximation to recurrent laryngeal nerve, which was carefully isolated and
dissected. Again, there appeared to be enlarged lower lymph nodes with a
question of a parathyroid gland within these lymph nodes and as such, a pre
excision of parathyroid hormone level was drawn. Of note, the pre incision
parathyroid hormone level measured 200 pg/mL, which was elevated and
consistent with the preop diagnosis. After excision of the enlarged lymph
nodes with a questionable parathyroid adenoma from the left, we took a 5-
minute and 10-minute sample of parathyroid hormone which was performed by the
Anesthesia Service. We then continued dissection as the lab results were
pending. We went to the superior pole and found the left superior parathyroid
gland, which appeared to be within normal limits. This was left intact and
kept out of harm's way. We then proceeded to dissect the thymus while
awaiting the return of the lab values, which took approximately 60 minutes.
The thymus gland was carefully isolated and brought to the transcervical
incision and resected using Harmonic Scalpel. An another level was drawn 60
minutes post excision after the thymus was removed. Levels came back after
the thymus was removed at 199 and 185 respectively, which signified that the
parathyroid gland was not removed. We then carefully dissected on the left
inferior aspect below the left clavicle in the pre pharyngeal space on the
right and on the left, we were unable to find the parathyroid gland. On the
left side, we also dissected in the retroesophageal space and again we were
unsuccessful in localizing the enlarged adenoma. At this point in time, after
5 hours of operative intervention, it was thought that the patient would
benefit from closure and to allow the area to heal and to have another workup
performed in approximately 3 to 4 months' time. Of note, the left vagus nerve
did not stimulate prior to dissection on the left side. On the right, the
vagus nerve did stimulate; however, after gentle traction from medialization
of the thyroid lobe, there appeared to be a mild pyrexia. Based on this, we
bolstered our decision to terminate the procedure at this point in time, and
continue at a later date. We then proceeded to close the neck after
assessment of adequate hemostasis, which was performed with a combination of
Bovie cautery and Fibrillar. The median raphae was first closed in a running
fashion and the thyroid cartilage down to the sternal notch with a small area
left open for release of any fluid accumulation if necessary. This was
performed using chromic suture. The platysma muscle was then closed in an
interrupted fashion using 3-0 chromic suture as well. The skin was then
closed in a subcuticular fashion using 5-0 fast gut.