# Retroperitoneal lymph node dissection



## daniel (Mar 5, 2014)

these are the codes I'm looking at

CPT 49204
CPT 38747

Can I get some input on what you would select? Thanks



OPERATION PERFORMED:   
Resection of retroperitoneal mass.
Retroperitoneal lymph node dissection.
Right adrenalectomy.
Resection of liver mass (metastasectomy).  See Dr. x operative report.


FINDINGS:   
A 6 cm x 8 cm mass under the vena cava extending from below the right renal hilum extending to the right adrenal gland.  This mass was resected en bloc.  Also resected were the distal ureter to the resection margin and the gonadal vein and the adrenal gland.   
Peri-venocaval, periaortic, and intra-aortocaval lymph nodes were removed.   
Liver mass resected.  There was a 4 cm x 3 cm mass on the inferior surface of the liver adjacent to the right renal hilum (please see Dr. De Vera's report).
Right adrenal gland removed in the en bloc resection.   
Diaphragm intact.
The renal vascular hilum was re-resected.


DESCRIPTION OF PROCEDURE:  This patient had undergone a right radical nephrectomy for high-grade renal cell carcinoma in November 2013.  The patient developed a retroperitoneal mass that was positive on PET-CT scanning.  The patient had positive lymph nodes in her initial resection.  After a communication with the patient's medical oncologist and the patient, it was decided to resect the visible disease in preparation for further systemic therapy.    


After the patient was sterilely prepped and draped, a time-out was done verifying the surgical parameters.  A midline incision was made from approximately the symphysis pubis to below the umbilicus.  The Bookwalter retractor was placed.  There were no palpable abnormalities.  Next, the right colon was mobilized by making an incision in the line of Toldt and reflecting the right colon medially.  When the vena cava was exposed, there was a palpable mass below the vena cava, extending from approximately the renal hilum up into the area of the adrenal gland.  The mass also extended posterior to the vena cava.  The right colon was mobilized medially and retracted to the left side of the patient's abdomen.  First, the inferior peri-venocaval lymph node tissue was removed.  A split-and-roll technique was used.  The tissue on the top of the vena cava was incised, and the lymph node tissue to the right side of the vena cava was resected, clipping lymphatic tissue proximal and distal.  This was approximately from the hilum down to the right common iliac vessels.  The lumbar vessels were identified.  They were double tied with 3-0 silk and transected.  The vena cava was then mobilized superiorly.  The mass was identified and it was dissected superiorly.  Portions of the psoas muscle were removed.  The lumbar vessels were identified, double tied with 3-0 silk, and transected.  The right renal hilum was identified.  The artery was double ligated where it emanated from the aorta, and it was transected.  The mass was dissected off of the vena cava at the level of the renal vein.  It was noted that there were previous staples used to control the renal vein.  The mass was dissected superiorly.  The adrenal vessels were identified, and both the artery and the vein were ligated with 3-0 silk and transected.  The Endo GIA RP45 was used to staple superior to the mass and the adrenal gland.  The adrenal gland was retracted inferiorly.  An incision was then made laterally in the peritoneum, and the mass and tissue were dissected off of the inferior and posterior portion of the liver.  The final lateral attachments were removed and the mass was removed and sent as specimen.  The right renal vein margin was re-resected using a Satinsky clamp to control the vena cava.  The renal vein margin was resected and the vena cava closed with 4-0 Prolene.  Next, a retroperitoneal lymph node dissection was performed, completely mobilizing the vena cava, retracting it to both the right and left side, and the intra-aortic caval and periaortic lymph node tissue was removed.  The lumbar vessels coming from the aorta on the right side of the ureter were ligated with 0 silk and transected to mobilize the aorta.  The left renal vein was mobilized.  The superior mesenteric artery was identified and preserved.  All the lymphatic vessels were transected.  


The liver mass was resected.  I assisted Dr. x in resecting the liver mass.  The mass was resected and sent as specimen.  There was good hemostasis.  Please see Dr. x operative report for the liver mass resection.  There were two renal arteries.  The right renal artery stumps were stick-tied with 5-0 Prolene to reinforce the silk sutures.  Inferiorly, the ureteral margins of the gonadal vessels were resected with some lymph node issue, and psoas tissue was sent as a separate specimen.  All of the visible mass had been removed, and normal lymph nodes had been removed.  The operative site was irrigated.  Hemostasis was achieved.  FloSeal was placed in the operative site.  The right colon was replaced laterally, and the bowel repositioned.  The ends of the incision were reinforced with #1 Vicryl, and the incision was closed with #1 double-looped PDS.  One suture was started from the top, one from the bottom, and the two sutures were tied supraumbilically.  The subcutaneous tissue was then irrigated copiously with water.  The subcutaneous tissue was closed with 0 Vicryl and the skin closed with staples.


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