SonyaLynn51
Contributor
Postop diagnosis: right side ureteropelvic junction obstruction Procedure: Extensive lysis of adhesions (2 hrs) Cytoscopy, right side retrograde pyelogram, right side ureteral stent placement, 6x28 cm Double J Robotic Laparascopic assisted right side pyeloplasty (dismembered) transposition of crossing vessel. (Modifier 22) Details: The patient was properly identified in the preoperative area and taken to the operating room and placed on the table in the supine position. EPC cuffs were placed and activated. IV antibiotics were given preoperatively. General anesthesia was induced. She was initially placed in dorsolithotomy, prepped and draped in sterile fashion. We began with a cystoscopy which was negative for any tumors. The right ureteral orfice was cannulated with a ureteral catheter and we performed a retrograde pyleogram which delineated the collecting system and showed the dilated renal pelvis. A 6x28 ureteral stent was placed with wire and flouroscopic guidance. We placed a 3 way 22f foley catheter. Patient was then placed in right up lateral position. Pressure points were padded. Axillary roll was placed. Patient was then prepped, draped in usual sterile standard fashion. Veress needle was used to obtain pneumo-peritoneum successfully. We used a camera to place the first an intra-abdominal port, We then proceeded to perform extensive lysis of adhesions for 2 hrs. with laparoscopic scissors. It was a complex take down, we did not notice any injury to the bowel. Robotic ports were placed under direct visualizations. The Robot was docked. The white line of Toldt was cut and the colon was reflected. This was carried down to valley, and the ureter and gonadal vessel were identified. The tail of gerota's was lifted off the psoas and the kidney was lifted. Her previous procedure caused extensive scarring which added time and complexity to the case (Modifier 22). We visualized the ureter and dissected this circumferentially to the renal pelvis. We did encounter a small crossing vessels that would account for obstruction. We transected and dismembered the ureter at the UPJ. We performed a tension free, mucosa to mucosa dismembered pyeloplasty over the stent in typical fashion using 4-0 monocryl sutures. We placed a drain in the field and this concluded the case. The robot was undocked. The robotic ports were removed under direct visualization without evidence of bleeding. The skin was closed with 4-0 monocryl and reinforced with dermabond. Case was concluded and patient tolerated the procedure well. Anesthesia was reversed and patient was extubated, taken to recovery in stable conditon. Patient was admitted to the floor for routine post op care. I came up with 50544-22,RT 50949-benchmark to 50760-51,RT 52332-51,RT 74420-51,26 Appreciate any help!!!