Robot assisted laparoscopic cystectomy w/bilateral lymphadenectomy Robotic intra-corporeal Ileal conduit urinary diversion-51999 benchmarked to 51595

Willow11

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Pre/Post operative Diagnosis:
1. Bladder cancer

Procedure:
1. Robot assisted laparoscopic cystectomy with bilateral lymphadenectomy
2. Robotic intra-corporeal Ileal conduit urinary diversion
3. Robotic bowel anastomosis

Indications: 80yo male with T2 bladder cancer. He has elected to proceed with robotic cystectomy and ileal conduit.


Specimens:
1. Cystoprostatectomy specimen to pathology
2. Bilateral ureteral margins for frozen section
3. Right and left pelvic lymph nodes to pathology

Procedure:

The Veress needle was introduced through the umbilicus into the abdomen. The abdomen was insufflated to 15 cm of water pressure. Above the umbilicus an 8 mm incision was made with the Bovie. The camera port was inserted into the abdomen. The camera was immediately inserted and used to make sure there was no injury to the underlying abdominal contents. On the patient's right side 2 more 8 mm ports were placed into the abdomen after incising the skin with the Bovie. On the patient's left side a 5 mm, an 8 mm, and a 10 mm port were all placed after incising the skin with the Bovie. All the ports were placed with the camera in the abdomen to ensure no injury to the underlying abdominal contents.

The robot was brought in and docked to the ports. The robotic instruments were inserted under direct visualization with the camera. The sigmoid colon was mobilized sharply. An incision was made in the White Line of Toldt to mobilize the left colon partially. The left ureter was dissected in the retroperitoneum at the level of the iliac vessels. The ureter was sharply dissected distally to the level of the bladder. The superior vesicle artery was encountered and divided using the vessel sealer device. The ureter was dissected down to the bladder. The ureter was then doubly clipped with Wek clips. The ureter was divided and a margin was sent for frozen section. The ureter was then mobilized cephalad from the iliac vessels as much as possible. The frozen section returned with a negative margin.

Attention was then turned to the right side of the pelvis. The terminal ileum and the appendix were visualized. The right colon was mobilized sharply by incising the White Line. Small bowel was retracted out of the retroperitoneum. The retroperitoneum was incised overlying the iliac vessels. The ureter was identified and sharply dissected. The ureter was dissected down to the level of the bladder similarly to the left side. The superior vesical artery was divided using the vessel sealer. The ureter was doubly clipped at the level of the bladder. The ureter was divided and a margin was obtained and sent to pathology. The margin came back as negative.

The posterior peritoneum was incised in the space of Douglas. The vasa were dissected down to the SVs. The SVs were mobilized sharply. I created a plane posterior to the SVs and the prostate. This was somewhat difficult as the tissue planes were fairly fibrotic in nature. I could not visualize any gross tumor. Eventually the plane was developed down to the prostatic apex.

Starting on the left side, the bladder was retracted anteriorly. The bladder pedicles were identified and divided using the vessel sealer. I was careful to stay posterior to the ureter and the SVs. On the left side it was somewhat difficult to find the right plan posteriorly due to heavy fibrosis. Once again, I did not visualize any gross tumor extension from the bladder. Eventually the pedicles were divided down to the level of the endopelvic fascia. I then opened the anterior peritoneum lateral to the obliterated umbilical artery on the left side. The peritoneal incision was carried down lateral to the bladder. The vas deferens was divided using the vessel sealer device.

The bladder pedicles were divided on the right side in a similar fashion using the vessel sealer device. I created a plane below the bladder and SVs until the prostate pedicles could now be visualized. I opened the endopelvic fascia on both sides using sharp dissection. The endopelvic fascia was opened as far towards the prostate apex as feasible. The prostate pedicles were then divided using the vessel sealer. The prostate was then free up to the apex.

I then used the 30 degree lens upward to visualize the Urachus. This was dissected just caudally from the umbilicus and divided using the vessel sealer device. I then proceeded to dissect the anterior peritoneum off of the anterior abdominal wall and enter the space of Retzius. Eventually the bladder was mobilized and the pubic bone was encountered. The anterior prostate was then visualized. Fat was removed from the anterior surface of the prostate. The endopelvic fascia was visualized and opened on both sides of the prostate. The prostate was dissected off of the pelvic floor muscles on both sides. The dorsal vein complex was identified. This was ligated with an 0 PDS suture. The dorsal vein complex was divided using electrocautery.

The bladder neck was identified and opened anteriorly. The Foley catheter was visualized and used as traction on the prostate. The foley was pulled through the incision and a Wek clip was placed. The foley was cut downstream from the Wek clip. The posterior bladder neck was divided. The rhabdosphincter was divided. The cystoprostatectomy specimen was freed at this point. The specimen was pushed into the upper abdomen. The pedicles were examined and there appeared to be excellent hemostasis.

A pelvic lymph node dissection was performed on the left side. The internal iliac vein was identified. The node packet was dissected off the medial aspect of the vein and then dissected back to the pelvic sidewall. The node packet was dissected distally to Cooper's ligament. The vessel sealer device was used to divide the node packet distally. Inferiorly, the obturator nerve is identified. The node packet is dissected proximally off the obturator nerve. The packet is dissected back to the bifurcation of the internal and external iliacs. The packet is divided at this point using the vessel sealer. The lymph node packet is then mobilized off of the external iliac artery. This is mobilized back to the bifurcation of the external/internal iliac artery. The packet is divided using the vessel sealer device. The packet is then removed with a spoon tip grasper and labeled for pathology. The obturator nerve is inspected and free of any injury. No significant bleeding is noted. The same procedure is performed on the patient's right side.

The sigmoid colon is then visualized and retracted anteriorly. On the patient's right side, gentle dissection underneath the sigmoid mesentary is performed below the aortic bifurcation overlying the sacral promontory. I am able to pass the prograsp forceps through the mesentery to the left side of the sigmoid colon. The left ureteral tagging suture is placed within the prograsp and the prograsp is gently pulled through under the sigmoid to reposition the left ureter into the right retroperitoneum.

At this point, there appears to be excellent hemostasis. Dr L took over at this point to perform the mesenteric incision to form the conduit and to perform the bowel anastomosis robotically. His note is dictated separately.

The suture line of the abdominal end of the conduit is opened with a scissors. The conduit is irrigated and suctioned copiously with normal saline. Two incisions are made in the butt end of the conduit using the scissors. These are 5mm incisions. Single J stents are placed through the conduit through each incision. The ends of the ureters are incised and spatulated. Bricker type anastomoses are fashioned using running 4-O monocryl sutures on the left side. On the right side I used two running 3-O barbed sutures to create the anastomosis. The single J stents were inserted into each ureter for about 20cm before completing the anastomses.

At this point, a 15fr blake drain is brought in through the lateral 5mm port on the patient's left side. The drain is positioned in the pelvis and under the conduit anastomosis. The pelvis is inspected and there is excellent hemostasis. The robotic instruments are removed and the robot is undocked.

A peri-umbilical incision is marked for about 4cm. The skin is incised with a scalpel and taken down to the fascia using electrocautery. The peritoneum is opened sharply and there is no bowel in the vicinity as the pneumoperitoneum was still intact. The abdomen was then deflated. The remnant of the foley catheter extending from the prostate is localized and the cystoprostatectomy specimen is removed intact.

A Rosebud type stoma is created. The skin is incised overlying the stomal marking lateral to midline on the right side. The fat is incised down to the fascia using the bovie. The fascia is cleared and a cruciate incision is made in the fascia. The posterior fascia and peritoneum are incised and opened. Two finger breadths can be passed through the rectus sheath and the incision. A Babcock clamp is then used to pull the conduit up through the opening. The conduit is sutured to the fascia in four quadrants using 2-O vicryl sutures. Four 3-O vicryl sutures are then used to invert the stoma. The intervening stomal mucosa is sutured to the skin with interrupted 3-O vicryl sutures. The stoma is matured at this point.

The previously placed Blake drain is sutured to the skin with a 2-O nylon suture. The midline incision is closed with a running O pds loop suture. The incision is irrigated with saline. The skin incisions are closed with staples. The urostomy appliance is placed.

51999 benchmarked to 51595 and 55866
 

Willow11

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Thank you for your help. You state that this is one method of correct billing. Is there another I should be made aware of?

Thank you again!!
 
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Another method of billing for this scenario would be 51999 and bench marked to 51590 and add 38571 for the bilateral pelvic node resection as well as 55866 for the radical prostatectomy.
 
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