Rusty on CT surgery

jewlz0879

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OPERATIONS:
1. Mediastinoscopy.
2. Left thoracotomy.
3. Left lower lobectomy.
4. Resection of chest wall mass.


DESCRIPTION OF PROCEDURE: While in supine position, the neck was extended. The anterior neck was
prepared with ChloraPrep solution and draped in a sterile manner with sterile linens and towels.
A small transverse neck incision was made and taken down through the soft tissues utilizing electrocautery
for hemostasis. Pretracheal fascia was encountered and a blunt passageway was directed into the
superior mediastinum.

Afterwards, the mediastinoscope was inserted and continued dissection to remove lymph nodes. These
were resected and sent to pathology. Frozen section analysis revealed benign nodes. In the process of
the blunt dissection, a pericardial cyst was ruptured draining clear watery fluid. Once good hemostasis
and dryness was noted within the mediastinal space, the scope was removed and the neck tissues were
closed with interrupted sutures of 3‐0 Vicryl. The skin margin was approximated with a running
subcuticular stitch of 4‐0 Vicryl.

Patient was turned to the right lateral decubitus position. The anterior left chest was prepared with
ChloraPrep solution and draped in a sterile manner with sterile linens and towels. A small curvilinear
lateral thoracotomy incision was made and taken down through the soft tissues utilizing electrocautery
for hemostasis and as a muscle sparing incision. Dissection revealed a soft tissue mass directly beneath
and adjacent to the scapula. The mass was white in color with cystic pockets. The mass was excised and
frozen section analysis revealed benign fibro‐elastoma. The sixth intercostal space was entered with
severance of the posterior to prevent rib fractures and stretching of the intercostal nerves.
Examination of the left pleural space revealed a very large hiatal hernia with an intact hernia sac
compressing the lower lobe. The patient was placed in Trendelenburg position to assist in reducing the
effect of the hiatal hernia. No attempt to repair the hiatal hernia.

Hilar blunt dissection was undertaken to release the pleura. The inferior pulmonary ligament was taken
down to expose the inferior pulmonary vein. Several nodes were submitted to pathology and found
negative for tumor, including the carinal node. The major fissure was entered and bluntly dissected to
expose the pulmonary artery. Branches to the upper lobe were identified isolating them from those of
the lower lobe. Utilizing vascular stapling devices, the pulmonary structures to the lower lobe were
stapled and divided. Afterwards, the inferior pulmonary vein was divided with a TA vascular stapler. The
bronchus was mobilized to sweep the lymph nodes to the specimen. The TA stapling device was placed
across the lower lobe bronchus. Compression was applied and the lung was inflated. Only the upper lobe
inflated signifying correct application of the bronchial stapler. The bronchial stapler was deployed and
the bronchus was sharply severed with removal of the specimen from the wound. Bronchial margins
reported as clear of tumor.

The left pleural space was irrigated with warm saline solution while the bronchial stump was under water.
Anesthesia applied 40 cm of sustained pressure to the lung and no air leak was demonstrated. Good
expansion of the left upper lobe was identified.

Two 28‐French chest tubes were placed into the chest and brought through separate stab incisions. These
chest tubes were secured with 0 silk sutures. The seventh rib was reapproximated and fixed with a
titanium plate. Afterwards, intercostal space was approximated with several interrupted sutures of #2
Vicryl. The soft tissues were approximated with running sutures of 0 and 2‐0 Vicryl. The skin margin was
approximated with a running subcuticular stitch of 4 0 Monocryl.

The patient tolerated the procedure well. He was extubated and taken to the PACU in stable
hemodynamics and breathing well.

Am I on the right track here?

CPT 32480-LT; 39402 ( or should I use 38746 I don't see at least 4nodes removed); 19260-52 (no ribs removed-can or should I use the modifier 52?) or 21555 (no documentation of size i.e. 3cm). STS states that when no ribs are removed to use either 21555-21557.
 
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