TWilliam2019
Guru
38381 I feel I am missing codes could some one please help thanks
Procedure:
1. Tube thoracostomy, left
2. Video thoracoscopy converted mini-thoracotomy, right
3. Ligation of thoracic duct
4. Intercostal nerve block, right
Indications:
Mrs. Patient is a 44 y/o woman who is recently s/p L thoracic outlet decompression with 1st rib resection who developed a chyle leak and left chylothorax post-operatively. For these reasons, she was consented and brought to the operating room for the aforementioned procedures.
Findings:
1. Approximately 1500mL of chylous fluid drained upon placement of left tube thoracostomy
2. An approximate 150mL chylous right pleural effusion was present upon initial right video thoracoscopy
3. In order to ensure an extreme caudal extent of thoracic duct ligation in the right thorax, a small posterior-lateral thoracotomy was affected. Direct ligation of the thoracic duct was performed without incident
Specimens:
1. Segment of Thoracic Duct for permament
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 dual-lumen endotracheal intubation was affected. Monitoring lines were placed by anesthesia. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
Next, the left chest was prepped and draped in the usual sterile fashion. A 1cm skin incision was made in the anterior axillary line overlying the 5-6th interspace. The pleural space was then entered bluntly and a 28 Fr chest tube inserted. Approximately 1,500 mL of chylous fluid was drained. The chest tube was secured with suture and a sterile dressing applied.
Next, the patient was then repositioned in the left lateral decubitus position with their right side up. The right chest was then prepped and draped in the usual sterile fashion. A second surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
Next, an approximately 1cm skin incision was made overlying the 8th interspace in the anterior axillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. Additional working ports were placed under direct vision. The lung was reflected anteriorly to expose the posterior pleura and apex. A mild chylous pleural effusion was present. This was evacuated. Given this, and in order to ensure a caudal extent ligation of the thoracic duct, the decision was made to affect a small posterior-lateral thoracotomy to ensure adequate exposure. One of the working port incisions was extended with a 15 blade scalpel. Dissection was carried down through the subcutaneous tissues with electrocautery. The latissimus was divided and the interspace entered. The inferior pulmonary ligament was taken down with ligasure, as was a few small adhesions. The diaphragmatic sulcus was interrogated. The posterior pleural was incised with electrocautery just medial to the azygous vein. With careful blunt dissection, the thoracic duct was visualized in the space between the spine and aorta, posterior to the esophagus. The duct was ligated with three hemoclips superiorly and three hemoclips inferiorly at the level of the diaphragm. A 2cm portion of the duct was excised with Metzenbaum scissor to ensure a ductal structure. This was verified and sent to pathology as permament specimen. The hemithorax was copiously irrigated with warm saline and suctioned until clear. There was no residual chylous effluent identified in the right chest or eminating from the left chest tube. Next, 30mL of 0.25% Marcaine with epinephrine was instilled into the 5th-9th interspaces under direct vision in order to affect an intercostal nerve block. A cyro-freeze intercostal nerve block was also affected overlying the same interspaces.
Next, a 28Fr chest tube was placed. Hemostasis was verified. Several intercostal sutures of No. 2 Ethibond were placed to close the interspace. The lung was then reexpanded under direct vision. The latissimus was re-approximated with 0 Vicryl suture. All skin incisions were closed in layers with 0 and 2-0 Vicryl. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds. 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.
Procedure:
1. Tube thoracostomy, left
2. Video thoracoscopy converted mini-thoracotomy, right
3. Ligation of thoracic duct
4. Intercostal nerve block, right
Indications:
Mrs. Patient is a 44 y/o woman who is recently s/p L thoracic outlet decompression with 1st rib resection who developed a chyle leak and left chylothorax post-operatively. For these reasons, she was consented and brought to the operating room for the aforementioned procedures.
Findings:
1. Approximately 1500mL of chylous fluid drained upon placement of left tube thoracostomy
2. An approximate 150mL chylous right pleural effusion was present upon initial right video thoracoscopy
3. In order to ensure an extreme caudal extent of thoracic duct ligation in the right thorax, a small posterior-lateral thoracotomy was affected. Direct ligation of the thoracic duct was performed without incident
Specimens:
1. Segment of Thoracic Duct for permament
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 dual-lumen endotracheal intubation was affected. Monitoring lines were placed by anesthesia. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
Next, the left chest was prepped and draped in the usual sterile fashion. A 1cm skin incision was made in the anterior axillary line overlying the 5-6th interspace. The pleural space was then entered bluntly and a 28 Fr chest tube inserted. Approximately 1,500 mL of chylous fluid was drained. The chest tube was secured with suture and a sterile dressing applied.
Next, the patient was then repositioned in the left lateral decubitus position with their right side up. The right chest was then prepped and draped in the usual sterile fashion. A second surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
Next, an approximately 1cm skin incision was made overlying the 8th interspace in the anterior axillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. Additional working ports were placed under direct vision. The lung was reflected anteriorly to expose the posterior pleura and apex. A mild chylous pleural effusion was present. This was evacuated. Given this, and in order to ensure a caudal extent ligation of the thoracic duct, the decision was made to affect a small posterior-lateral thoracotomy to ensure adequate exposure. One of the working port incisions was extended with a 15 blade scalpel. Dissection was carried down through the subcutaneous tissues with electrocautery. The latissimus was divided and the interspace entered. The inferior pulmonary ligament was taken down with ligasure, as was a few small adhesions. The diaphragmatic sulcus was interrogated. The posterior pleural was incised with electrocautery just medial to the azygous vein. With careful blunt dissection, the thoracic duct was visualized in the space between the spine and aorta, posterior to the esophagus. The duct was ligated with three hemoclips superiorly and three hemoclips inferiorly at the level of the diaphragm. A 2cm portion of the duct was excised with Metzenbaum scissor to ensure a ductal structure. This was verified and sent to pathology as permament specimen. The hemithorax was copiously irrigated with warm saline and suctioned until clear. There was no residual chylous effluent identified in the right chest or eminating from the left chest tube. Next, 30mL of 0.25% Marcaine with epinephrine was instilled into the 5th-9th interspaces under direct vision in order to affect an intercostal nerve block. A cyro-freeze intercostal nerve block was also affected overlying the same interspaces.
Next, a 28Fr chest tube was placed. Hemostasis was verified. Several intercostal sutures of No. 2 Ethibond were placed to close the interspace. The lung was then reexpanded under direct vision. The latissimus was re-approximated with 0 Vicryl suture. All skin incisions were closed in layers with 0 and 2-0 Vicryl. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds. 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.