# trisegmentectomy



## cmacdonald (Jan 15, 2019)

What code would I used for a trisegmentectomy.  The surgeon said "The three segments were contiguous and were part of a single specimen. They were not three segments from different places."

32669, 32668, 32674 and S2900?


If they were from different places would I use the code 32669 a second time with a 59 modifier?

POSTOPERATIVE DIAGNOSIS:  Left upper lobe mass with frozen pathology
consistent with non-small cell lung cancer.
.
PROCEDURES:
1.  Robotic left upper lobe diagnostic wedge resection.
2.  Robotic left upper lobe division trisegmentectomy.
3.  Robotic mediastinal lymph node dissection.
4.  Multiple intercostal nerve blocks.
5.  Bronchoscopy.
.
INDICATION:  is a 55-year-old female, never smoker from China
who presented with an incidentally found left upper lobe lung mass.  Given
her demographic she is at high risk for a primary lung cancer, thus she
presented for elective resection of the mass.
.
DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room in
stable condition where general anesthesia was induced.  A double lumen
endotracheal tube was placed and verified with bronchoscopic evaluation.
We then placed her in the lateral decubitus position with the left side up,
prepped and draped in the usual sterile fashion and a timeout procedure was
done to ensure the correct patient and procedure.  This was a forearm
technique robotic lung resection.  This included two 12 mm robotic arms in
the 1 and 3 position and two 8 mm robotic ports in the 2 and 4 positions.
These were all placed in the 8th intercostal space above the 9th rib.  A
#15 mm access port was placed just above the diaphragm between the arms 1
and 2.  I also performed multiple intercostal nerve blocks with 0.25%
Marcaine with epinephrine.  We began by doing a large wedge resection of
the mass, which was in the apical posterior segment of the left upper lobe.
This was sent for frozen pathology, which did return as a low-grade
non-small cell lung cancer consistent with adenocarcinoma.  At this
juncture, given her age and the size of the tumor, I felt it was prudent to
complete anatomic lung resection.  As the tumor was in the apical posterior
division I opted for an upper division trisegmentectomy.  We began by
dissecting along the fissure and completing the posterior fissure with a
blue staple fire.  I also performed a mediastinal lymph node dissection
sending level 5 nodes for permanent pathology.  A regional lymphadenectomy
was also performed including several level X, XI and XII lymph nodes of the
left side.  Once our posterior fissure was complete, I dissected out the
pulmonary artery branches going to the left upper lobe.  There were 3
truncus branches, which I took with 2 separate vascular staple fires of the
robot.  There was an upper division vein, which was crossing over the first
PA branch, which I also took separately with a vascular load staple fire.
I then dissected along the PA distally to clearly identify the lingular PA
branches to ensure that these would be preserved.  There was one more PA
branch going to the posterior segment of the upper lobe, which I also took
with a vascular staple fire.  Once all of our PA branches going to the
upper division were dissected, we dissected out the upper division
bronchus.  I personally performed a bronchoscopy at this juncture to ensure
that the lingular bronchus was preserved.  A blue load staple fire was
taken to come across the upper lobe division bronchus.  At this juncture,
multiple staple fires of a green load were then taken to complete the upper
division trisegmentectomy.  At this juncture, we removed our vessel loop,
which we had used for vessel isolation as well as the rolled gauzes which
we had placed 2 in the chest to help in dissection.  Once these were
removed and we ensured that all counts were correct, I tunneled a 19-French
Blake chest tube into the thoracic cavity draped from anterior to
posterior, superior to inferior and terminating in the posterior sulcus.
We then resumed to lung ventilation to ensure that both the lingula as well
as the lower lobe reinflated without difficulty.  Estimated blood loss was
minimal at less than 20 mL.  There were no apparent intraoperative
complications.  I was present throughout the entire procedure.  We then
undocked the robot, removed our robotic ports and the incisions were closed
in a layered fashion with Vicryl sutures and the skin was sealed with
Dermabond.


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## autumn_breeze (Nov 13, 2019)

Hello cmacdonald, I know this is an old post but wondering if you figured out how to code this. I have the same question. Based on my research and talking to the surgeon, I'm being told this is anatomic
equivalent of a right upper lobectomy (aka: ligular sparing lobectomy). My question is should I add a modifier -52 since ligular is not removed? I was just curious as to how you coded yours.
Based on your report I would have coded this as below - again with the question of modifier -52.
32663
32674
32668
S2900

Thanks.


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