TWilliam2019
Guru
Procedure:
1. Flexible bronchoscopy
2. Left Thoracotomy
3. Complete Pneumonectomy, Left 32480 LT
4. Pedicled Serratus Muscle Flap WHAT WOULD THIS CODE BE IF CODABLE?
Indications:
53 y.o. male who presented for evaluation of Necrotizing Pneumonia. For these reasons, he was consented and brought to the operating room for the aforementioned procedures.
Procedure Details:
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with endotracheal intubation was affected. Monitoring lines were placed by anesthesia. A surgical timeout was used confirm patient identity as well as the surgery to be performed. Next, The patient was then repositioned in the right lateral decubitus position with their left side up. The left chest was then prepped and draped in the usual sterile fashion. Next, a standard thoracotomy incision was made. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered and a partial rib resection was completed to aid in retraction.
Next, the lung was reflected superiorly and the inferior pulmonary ligament was taken down. The lung was then reflected anteriorly and the posterior hilum was then dissected. The lung was then reflected caudad and the superior hilum was dissected and then the lung was reflected posteriorly and the anterior hilum was dissected free to completely mobilize the lung. The left upper lobe was very dense, necrotic and very immobile. Next, the superior pulmonary vein was then identified, dissected, and isolated with a vessel loop. Next, with a vascular staple load the superior pulmonary vein was then transected. This then exposed the one of the truncus anterior branches which was isolated and transected with a vascular load. Next, the lung was then returned to the normal anatomical position and the fissure was then entered to isolate the interlobar pulmonary artery and its branches. The posterior fissure was then completed with a GIA stapler. This then exposed the posterior ascending branch which was isolated and transected with a GIA vascular load. Next, the anterior fissure was then dissected and transected with a GIA purple covidien load. This then exposed the upper and lower lobe bronchus and the lower lobe bronchus at this time appeared to be involved in the necrotizing infection of the upper lobe. At this point because the necrotizing pneumonia was affecting the entire upper lobe and the airway of the lower lobe I decided it would be best to perform a complete pneumonectomy back to healthy appearing tissue. I decided to resect the lower lobe in the standard fashion because of the immobility of the upper lobe. Next, I then dissected out the superior segmental and basilar branch pulmonary arteries of the lower lobe and transected them with a GIA vascular load. Next, the inferior pulmonary vein was then isolated and transected with a GIA vascular load. Next, I then transected a portion of the lower lobe bronchus to remove the left lower lobe to allow more space in the chest and I passed that portion of the lung off to pathology. Next, attention was then turned back to the upper lobe. I reflected the lung caudad and again the lung was so dense and immobile that as the lung was being reflected another truncus anterior branch of the PA had torn and was controlled with direct pressure. I then isolated the PA branch and was able to pass a vascular stapler under the branch and transect it. There was still a small hole in the PA that was then repaired with a 5-0 pledgeted suture. Next, the lingular branch of the PA was then isolated and transected with a GIA vascular load. Next, the left main bronchus was then identified and transected with a GIA black load and the remaining lung was then removed and passed off to pathology. Next, the chest cavity was irrigated and hemostasis was verified.
Next, I then dissected out and isolated a serratus muscle flap and dissected back to a pedicle and positioned it into the chest to cover the bronchial stump. The muscle flap was tacked down with several interrupted 3-0 vicryl sutures. A single 28Fr Blake chest tube was placed and directed towards the apex.
The ribs were then re approximated with number 2 vicryl sutures. All skin incisions were closed in layers with 0, 2-0 Vicryl and the skin was closed with staples.
Next, the anesthesia team then switched out the double lumen endotracheal tube for a single lumen. I then passed the bronchoscope into the airway and the entire airway was inspected. The left main stump was closed and appeared intact. The scope was then withdrawn and all the secretions were then suctioned free and the bronchoscope was removed.
At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the postanesthesia recovery unit in stable condition having tolerated the procedure well.
1. Flexible bronchoscopy
2. Left Thoracotomy
3. Complete Pneumonectomy, Left 32480 LT
4. Pedicled Serratus Muscle Flap WHAT WOULD THIS CODE BE IF CODABLE?
Indications:
53 y.o. male who presented for evaluation of Necrotizing Pneumonia. For these reasons, he was consented and brought to the operating room for the aforementioned procedures.
Procedure Details:
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with endotracheal intubation was affected. Monitoring lines were placed by anesthesia. A surgical timeout was used confirm patient identity as well as the surgery to be performed. Next, The patient was then repositioned in the right lateral decubitus position with their left side up. The left chest was then prepped and draped in the usual sterile fashion. Next, a standard thoracotomy incision was made. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered and a partial rib resection was completed to aid in retraction.
Next, the lung was reflected superiorly and the inferior pulmonary ligament was taken down. The lung was then reflected anteriorly and the posterior hilum was then dissected. The lung was then reflected caudad and the superior hilum was dissected and then the lung was reflected posteriorly and the anterior hilum was dissected free to completely mobilize the lung. The left upper lobe was very dense, necrotic and very immobile. Next, the superior pulmonary vein was then identified, dissected, and isolated with a vessel loop. Next, with a vascular staple load the superior pulmonary vein was then transected. This then exposed the one of the truncus anterior branches which was isolated and transected with a vascular load. Next, the lung was then returned to the normal anatomical position and the fissure was then entered to isolate the interlobar pulmonary artery and its branches. The posterior fissure was then completed with a GIA stapler. This then exposed the posterior ascending branch which was isolated and transected with a GIA vascular load. Next, the anterior fissure was then dissected and transected with a GIA purple covidien load. This then exposed the upper and lower lobe bronchus and the lower lobe bronchus at this time appeared to be involved in the necrotizing infection of the upper lobe. At this point because the necrotizing pneumonia was affecting the entire upper lobe and the airway of the lower lobe I decided it would be best to perform a complete pneumonectomy back to healthy appearing tissue. I decided to resect the lower lobe in the standard fashion because of the immobility of the upper lobe. Next, I then dissected out the superior segmental and basilar branch pulmonary arteries of the lower lobe and transected them with a GIA vascular load. Next, the inferior pulmonary vein was then isolated and transected with a GIA vascular load. Next, I then transected a portion of the lower lobe bronchus to remove the left lower lobe to allow more space in the chest and I passed that portion of the lung off to pathology. Next, attention was then turned back to the upper lobe. I reflected the lung caudad and again the lung was so dense and immobile that as the lung was being reflected another truncus anterior branch of the PA had torn and was controlled with direct pressure. I then isolated the PA branch and was able to pass a vascular stapler under the branch and transect it. There was still a small hole in the PA that was then repaired with a 5-0 pledgeted suture. Next, the lingular branch of the PA was then isolated and transected with a GIA vascular load. Next, the left main bronchus was then identified and transected with a GIA black load and the remaining lung was then removed and passed off to pathology. Next, the chest cavity was irrigated and hemostasis was verified.
Next, I then dissected out and isolated a serratus muscle flap and dissected back to a pedicle and positioned it into the chest to cover the bronchial stump. The muscle flap was tacked down with several interrupted 3-0 vicryl sutures. A single 28Fr Blake chest tube was placed and directed towards the apex.
The ribs were then re approximated with number 2 vicryl sutures. All skin incisions were closed in layers with 0, 2-0 Vicryl and the skin was closed with staples.
Next, the anesthesia team then switched out the double lumen endotracheal tube for a single lumen. I then passed the bronchoscope into the airway and the entire airway was inspected. The left main stump was closed and appeared intact. The scope was then withdrawn and all the secretions were then suctioned free and the bronchoscope was removed.
At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the postanesthesia recovery unit in stable condition having tolerated the procedure well.