Wiki Robot assisted laparoscopic cystectomy with bilateral lymphadenectomy and Ileal conduit urinary diversion - CPT code

Miko24

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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.

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 Small bowel was retracted out of the retroperitoneum.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 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 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. 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. 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. The bladder was very adhered and this was a difficult dissection. Eventually the bladder was mobilized and the pubic bone was encountered on the left side. The right side of the bladder was densely adhered to the pubic bone. Sharp dissection was used to separate the bladder from the pubic bone on the right side. In the process, it was noted that the obturator nerve was divided. Eventually the anterior bladder was separed and 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.

An 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 proximal portion of the obturator nerve was sharply mobilized. I reapproximated the obturator nerve with two 3-O V lock sutures.

At this point, there appears to be excellent hemostasis. The patient is repositioned supine. The robotic instruments are removed. The ports are removed under direct visualization. The robot is backed away from the table. The port incisions are closed with staples. A midline incision is made from just above the umbilicus to approximately 2cm below the umbilicus. The incision is carried down through the fascia and the peritoneum is opened. The abdomen is entered.

Both of the ureters are identified and tagged. Frozen sections are noted to be negative. The terminal ileum is identified. One Kocher length is measured from the terminal ileum and marked with the silk suture. A second Kocher length is marked from this spot and labeled with a silk suture. The mesentery is backlighted and the arcades are visualized. The mesentery is divided at each of the suture locations using the ligasure device. The bowel is divided at each location using a 60mm endoscopic stapler with blue loads. The conduit is placed inferiorly. A side to side bowel anastomosis is then performed using the 60mm endoscopic stapler with blue loads. The bowel limbs are approximated side to side using silk sutures. Then staple lines are fired in each direction and then again over the defect. The staple line is oversewn with 3-O silk sutures. The mesenteric defects are closed with 3-O silk sutures.

The abdominal end of the conduit is opened with a Metz. The conduit is irrigated copiously with normal saline. Two incisions are made in the butt end using the Bovie. 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 interrupted 4-O monocryl sutures at the apex. Running 4-O monocryl sutures are then used to complete the remainder of each anastomosis. The single J stents were inserted into each ureter for about 20cm before completing the anastomses.

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 usin 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 sutures to the fascia in four quadrants using 3-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.

A 15 French Blake drain was placed through the abdominal wall in the left lower quadrant. The 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.

55866
38571
51999 (51590)
Illeal conduit diversion - is that included in the 51590?

Or would this all be coded as open?
 
Your coding is not correct. Bench mark the 51999 to 51570, an open total cystectomy, and also bill for an open ileal conduit with 50820-50 as reported in the operative report. Some carriers will include the node resection in the 51999, bench marking then to code 51575 and not paying for the node resection separately. The coding would then be 51999, 55866, and 50820-50. When billing separately for each procedure, code 51999, 55866, 38571, and 50820-50.
 
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