Need some help on this one. Can I code for the Mediastinal Mass on this or would this be bundled with the Thyroidectomy ?

PREOPERATIVE DIAGNOSIS: Diffuse enlarged goiter of thyroid.

POSTOPERATIVE DIAGNOSIS: Diffuse enlarged goiter of thyroid plus ectopic mediastinal thyroid mass.

PROCEDURES PERFORMED: Total thyroidectomy with mediastinal exploration and incisional biopsy of mediastinal mass (frozen section confirms thyroid tissue).

OPERATIVE PROCEDURE: The patient was taken to the operating room after obtaining informed consent and placed on the operating table in a supine position. Following the achievement of adequate general endotracheal anesthesia, the patient’s head was extended over shoulder roll. The anterior neck was prepped with Betadine gel and sterilely draped.

The patient had a visibly enlarged thyroid gland bilaterally. A transverse incision was made and deepened through the platysma muscle. Superior and anterior flaps were raised and the deep anterior cervical fascia was opened in the midline preserving the strap muscles and exposing the thyroid gland. Attention was directed to the patient’s left lobe initially. The lobe was diffusely enlarged and heterotropic in appearance. Superior and inferior pole vessels were controlled with clips as was the middle thyroid vessel. The recurrent laryngeal nerve was identified and protected throughout its course and a parathyroid gland and the area just superior to the middle thyroid vessel was identified and preserved. The inferior parathyroid gland was never clearly identified. A full complete left thyroid lobectomy was performed. The isthmus was incomplete and so this lobe was submitted as a separate specimen. A suture marked the superior pole of the left lobe.

Attention was directed to the right side. Identical surgical findings were encountered with similar size enlargement of the right lobe and identical surgical technique was employed to remove the entirety of the right lobe. A finger of thyroid tissue abutting down posteriorly towards the tracheoesophageal groove required tedious dissection to remove this part of the thyroid tissue along with the remaining lobe and protect the recurrent laryngeal nerve as well. A parathyroid gland was identified and the soft tissue left behind on the right side of the neck. Dissecting the right lobe off of the trachea, and extension of this right inferior pole extended down into the sternal notch and this was followed with blunt and electrocautery dissection. The thyroid lobe was separated from this tissue only by a small strand of connective tissue. So, this right thyroid lobe was also sent down to pathology as a separate specimen with the suture marking the superior pole. Dissecting in the sternal notch region, the nodular mass aforementioned, was noted to extend considerable down beneath the sternum along the right carotid artery and an area of tissue, which resembled sinus tissue was excised and submitted to pathology. Dissecting this nodular mass more fully it was concerned that the blood supply to this mass may be originating from the innominate artery and without sternal split, full resection of this mass was not advisable at this time.

Intraoperative consultation with Dr. Charles Everson, Cardiothoracic Surgeon was obtained who inspected the area as well and agreed with the decision to perform an incisional biopsy of this mediastinal mass and submit this to pathology for examination. The pathology confirmed thyroid tissue. It was elected to evaluate the previously resected right and left thyroid lobes with presence of malignancy and approach the management of this mediastinal ectopic thyroid tissue accordingly based upon that pathology report.

The specimen previously sent to pathology again was confirmed as thyroid tissue in the mediastinum. The cut surface of the thyroid and the mediastinum were cauterized and FloSeal was applied to this area as well as both and right and left tracheoesophageal grooves.

The wound was then closed anatomically with Vicryl suture and subcuticular 4-0 Prolene suture and for the skin closure with Steri-Strips and OpSite. The patient tolerated the procedure well, was awakened from general anesthesia without complication, and transferred to the recovery room in satisfactory condition.