# Minimally invasive esophagectomy



## Coder708 (Dec 29, 2009)

I am pulling my hair out any guru's who can help. I put Cpt codes that i came up with.. They may all be bundled.. ANY HELP I would so appreciate it 

PROCEDURES:
1.  Minimally invasive esophagectomy.                       CPT 43289
2.  Right thoracoscopy with mobilization of esophagus. CPT??????
3.  Laparoscopy with mobilization of stomach and creation of gastric
conduit.                                                               CPT?????
4.  Placement of feeding  jejunostomy tube.               CPT 44015
5.  Botox injection of pylorus.                                   CPT       ????
6.  Left neck exploration and creation of end-to-side esophagogastric
anastomosis. ??????? cpt
7.  Bronchoscopy. ?????? cpt

DESCRIPTION OF PROCEDURE:


- PREOPERATIVE DIAGNOSIS:
Cancer of the gastroesophageal junction status post induction
chemoradiotherapy.
POSTOPERATIVE DIAGNOSIS:
Cancer of the gastroesophageal junction status post induction
chemoradiotherapy.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed initially supine
on a stretcher. A thoracic epidural was placed, followed by Foley
catheter, A line, and IVs. The patient was intubated and a double-lumen
endotracheal tube was placed. Its position was confirmed
bronchoscopically. The patient was then positioned prone on the operating
table with care taken to pad his head and arms appropriately. The arms
were abducted at the shoulder at 90 degrees and the elbows again were at
90 degrees. The table was jackknifed at 25 degrees at the hips and a bean
bag was rolled underneath his right side to elevate his chest. After
prepping and draping the right chest in the appropriate fashion,
landmarks were identified with a marker and a 5 mm stab incision was made
just at the tip of the scapula. Insufflation was performed by inserting a
Veress needle. A 5 mm port was placed followed by the 5 mm camera. There
were no adhesions of the lung to the chest wall. A 12 mm port was placed
in the anterior axillary line at approximately the fifth intercostal
space and another 5 mm port was placed in the posterior axillary line at
approximately the seventh intercostal space. Starting out with a hook
cautery, the pleura was incised overlying the esophagus. The azygous vein
was dissected free and an Endo-GIA stapler was used to transect it. The
esophagus was encircled with a 5/8 Penrose drain which was stapled off
with a blue load of the stapler. This Penrose drain was used as a handle
to help mobilize the esophagus all the way up to the thoracic inlet.
Lymph nodes were harvested from the subcarinal space and sent as a
separate specimen. The Penrose was tucked into the thoracic inlet. A
28-French chest tube was placed through the 12 mm port site. The lung was
seen to inflate under direct vision. The chest tube was secured with a
heavy silk suture. Two other 5 mm port sites were closed with Monocryl
and Dermabond.
The patient was then flipped supine back onto a stretcher and then placed
supine on the operating table. A footboard was placed at the feet, and
the patient's double-lumen tube was changed out for a Nim size 8
endotracheal tube. The patient had the subcutaneous probes placed for the
Nim tube on the anterior chest. The patient was prepped from mandible to
pubis. Dry sterile towels were used to score off where the neck incision
would be and the abdominal part of the case. Ioban  drape was placed,
followed by the surgical drapes. After marking anatomic landmarks, a
Hasson port was placed in the open technique in the RUQ. The camera was
inserted and there was no evidence of adhesions or peritoneal implants.
Under direct vision, an 11 mm port was placed in the left upper quadrant
just lateral to midline. Two 5 mm ports were placed at each of the the
costal margins. Another 5 mm port was placed far lateral on the right
abdomen for the liver retractor. The liver retractor was inserted and
placed under the left lateral segment of the liver and secured to the arm
on the bed. The patient was noted to have a significant number of
vascular structures along the lesser curve. It was quite possible that he
had a replaced left hepatic. Some of these vessels were clipped and some
were cauterized with the Harmonic scalpel. Dissection was carried over
the top of the hiatus and down the left crura. The fundus of the stomach
was then grasped as was the fat overlying the spleen and short gastrics
were taken along the fundus. The beginning of the arcade of the
gastroepiploic was identified and care was taken to stay away from this
vessel. The descending colon was in close proximity to the stomach with
some dense adhesions that were taken down with both blunt dissection and
the Harmonic. The stomach was elevated off the pancreatic bed and more
adhesions were taken down between the stomach and the pancreas. The
stomach was mobilized laterally to the level of the pylorus. The pylorus
could be grasped and elevated to the hiatus easily, signifying that
adequate mobilization had been performed. The space underneath the
esophagus was opened and more adhesions along the left crura were taken
down. The left gastric was identified and an Endo-GIA vascular stapler
was used to transect it. Next, the omentum was grasped and elevated
cephalad and the ligament of Treitz identified. Approximately 40-50 cm
from the ligament of Treitz, the bowel was tacked up to the anterior
abdominal wall using an Endostitch device. A finder needle was placed
through the anterior abdominal wall and into the bowel and air was
insufflated into the bowel to ensure that the needle was in the lumen.
The wire was then passed and it went easily. Over the wire, we then
passed the introducer for the feeding tube. This was placed easily into
the bowel and the feeding tube was then placed through the introducer.
The feeding tube was attached to the anterior abdominal wall using nylon
sutures and 3 more sutures were used to Stamm the bowel to the anterior
abdominal wall. Next, the fundus of the stomach was grasped and, starting
with a vascular load on the stapler, the conduit was created. Serial
firings of the Endo-GIA stapler were then used to create the conduit. A
small bleeding vessel along the lower border of the staple line was
secured with an Endostitch. The specimen was then sewn to the tip of the
conduit. The left neck was then opened using a 15 blade and this part was
performed by Dr. The esophagus was identified and encircled
with a Penrose drain. The nerve stimulator was used to identify the
recurrent laryngeal nerve and make sure that it was not encircled with
the esophagus. Blunt dissection was used to mobilize the cervical
esophagus. Specimen was then brought up through the neck, bringing the
conduit with it. This was done under direct vision to make sure that the
conduit did not twist. There was plenty of conduit at the neck and the
muscle of the esophagus was transected using a 15 blade. This allowed an
extra 1 cm of mucosa to be taken for the anastomosis. An end-to-side
anastomosis was performed. The gastrotomy was created and a 35 mm load of
the Endo-GIA blue load stapler was used to create the posterior wall. The
anterior wall was closed in a running fashion with Vicryl sutures. Prior
to closing the anterior part of the wall, the nasogastric was inserted
down through the stomach so it would sit near the xiphoid process. In the
stomach, the conduit was pulled down so it would be straight. There was
evidence of a small bleeding vessel along the right crura and this was
clipped for control. Under direct vision, the liver retractor was removed
and the EndoClose was used to close the 15 mm port site in the right
lower part of the abdomen. Vicryl sutures were used to close the larger
port sites fascia and Monocryl was used to close the skin. The neck was
closed as per routine. A size 15 JP was placed into the neck
and secured to the skin with nylon suture. At the end of the case,
therapeutic bronchoscopy was performed to make sure that there were no
secretions and the membranous portion of the trachea appeared normal. All
needle, instrument and sponge counts were correct at the end of the case
x2. The patient made 350 mL of urine and received 2900 mL of IV fluids.
Total blood loss for the case was 150 mL.


----------

