# Thoracotomy w left lower lobectomy



## ksb0211 (Jul 18, 2011)

I'm not very experienced with the "lung stuff"  LOL 
I'm hoping that I could get some other thoughts on this...
Thanks in advance.

PRE/POST-OPERATIVE DIAGNOSIS
Carcinoma of left lower lobe.

PROCEDURE
Left thoracotomy with left lower lobectomy.

SURGEON
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FIRST ASSISTANT
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ANESTHESIA
General.

DESCRIPTION OF PROCEDURE
The patient was taken to the OR.  After induction of general the patient was prepped with DuraPrep and draped sterilely.  A dual lumen tube was then placed.  A left posterolateral thoracotomy was planned.  The patient was sterilely draped.  The incision was made following the ribs below the level of the angle of the scapula.  Subcutaneous tissue was incised to the level of the fascia.  The pockets were formed over the fascia to allow for muscle-sparring entry.  Latissimus dorsi was retracted posteriorly and serratus anterior anteriorly.  Ribs were exposed and counted.  The 6th interspace was chosen.  The lung was deflated.  The intercostal muscle was incised.  The Finochietto rectractor was placed.  Exploration of the chest cavity revealed significant bullous disease of the left upper lobe.  Multiple adhesions were appreciated of the left upper lobe to the dome of the left pleural space.  Once these were freed I was able to start dissection along the hilum and hilum was opened circumferentially with electrocautery being careful to avoid underlying vascular structures.  Continued dissection was begun then at the level of the fissure posteriorly.  The pulmonary artery was found and its entry into the fissure identified.  Once this was done dissection was begun in the middle section of the fissure.  Again the pulmonary artery was identified and branches to the left upper lobe were preserved.  The lower lobe branches were identified and doubly ligated.  Once this was completed the inferior pulmonary vein was noted and controlled.  The TA 30V was then applied with good hemostasis achieved.  The fissures were completed utilizing a GIA with green staples.  The bronchus noted to have multiple anthracotic appearing lymph nodes.  These were sampled and some sent separately.  Once this was completed the TA 30 with green staples was applied to the bronchus along with blown good aeration of the upper lobe noted.  The stapler was fired and the lung was passed off.  The bronchus was air tested and no leak was noted of significance up to 30 mmHg of pressure.  With this completed a search was undertaken for other significant lymph nodes.  In the region of the aortopulmonary window an additional lymph node was identified and multiple nodes were noted to go with the specimen and also intralobar lymph nodes taken.  With all that is completed an angled 32 and a straight 36 chest tube were placed.  The wounds were closed.  The ribs were reapproximated.  Prior to leaving the operating room it was noted that he had more than expected air leak considering that the bronchus was completely intact.  Chest x-ray was ordered.  A small apical pneumothorax was noted.  The air leak persisted and the decision was to reopen the chest to address this issue.

The patient was reintubated.  The patient was then prepped and draped and draped sterilely.  Staples were removed.  The chest was easily opened with removal of the sutures.  The Finochietto retractor was placed.  It took a significant search, but it appeared that the air leak of significance was approaching the apex probably related to blebs and the tissue that was taken down on entering the chest cavity.  The TA 60 green was applied to the leaking tissue.  Once this was done, the air leak abated significantly.  Chest tubes were then replaced.  A 10 mm Jackson-Pratt drain was placed in the subcutaneous tissue.  The ribs were reapproximated with interrupted #1 Vicryl figure-of-8 sutures to the ribs.  The subcutaneous tissue was closed with 0 Vicryl.  Clips were applied to the skin and the estimated blood loss was 200 mL.  The patient tolerated the procedure without difficulty and taken to the recovery room and intensive care unit.


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## lisigirl (Jul 20, 2011)

Hi,

I'm not sure what you have questions on but I would only code the lobectomy - 32480.  Not enough lymph nodes were removed to bill for a lymphadectomy (38746) and the pneumo was probably caused by the surgery so I wouldn't bill for repairing it.

Lisi, CPC
eharkler@nmh.org


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