Surgery help

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Mack, CO
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Looking for any ideas on what the proper coding may be for this procedure:


1. Endoscopic Transoral Left-sided anterior maxillectomy approach to V2 and skullbase
2. Endoscopic V2 Foraminotomy with Ultrasonic Bone Aspirator
3. Endoscopic Dissection of the Left Sided V2 Branch of the Trigeminal Nerve
4. Endoscopic Excisional Biopsy of a branch of V2
5. Stereotactic Neuro Navigation

Description of procedure:
Patient was identified in the preoperative holding over surgical consent was obtained. An oral endotracheal tube was placed after inducing general anesthesia. The patient was placed in the supine position and rotated 180 degrees. She was prepped and draped in the usual sterile fashion. Afrin pledgets were placed inside the nose. We 1st began with our stereotactic navigation. After a deviation less than 2 mm was obtained, we agreed to move forward with the procedure.

We began with the anterior maxillectomy. A buccal gingival incision was made on the left side beginning from the frenulum to the level of the 2nd molar. The orbicularis was dissected with the needlepoint Bovie. The we then dissected down to the periosteum of the maxilla. Subperiosteal dissection was carried through with the Freer and the needlepoint Bovie. The foramen of V2 was then encountered. We did dissect around the foramen with the Freer. A foraminotomy was performed with the ultrasonic bone aspirator. Once this was completed to satisfaction, using a 1 mm Kerrison we performed a moderately-sized maxillectomy to provide exposure for the entire bony foramen of V2. At this point we took the ultrasonic bone aspirator to enter the foramen through the antra of the maxillary sinus to extend our foraminotomy. This did allow is to dissect the nerve. The neurovascular structure was dissected. There was some bleeding that occurred more proximally which was controlled with electrocautery. We then dissected the V2 until it arborizes after the foramen. We then had the exposure necessary for our biopsy. A lateral branch of V2 was exposed and dissected free. We clipped this with the small clip proximally. Using the micro scissors we did excise a piece and sent it for frozen section. Frozen section analysis returned that this was an adequate specimen to determine whether or not there is perineural invasion. However there was no gross squamous cell carcinoma noted. Further immunostaining would be needed. Hemostasis was achieved with direct pressure and Afrin pledgets. The incision was closed in layers with deep interrupted 3-0 Vicryl suture, final closure was achieved with horizontal mattress sutures, and a running locking whipstitch. The patient was awakened in stable condition.
 
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