# Gyne/onc - Infrarenal Lymph node dissection



## maybabysgirl (Oct 1, 2012)

Dx: 183.2 Fallopian tube cancer 

I am looking for a CPT code for Infrarnal Lymph node dissection. I was told to use 38572 as it encompasses both the Aortic and Infrarenal Lymph nodes. Please assist me with this. I was thinking use 38780. 

The op report is as follow: 

FINDINGS: At the time of surgery, intraabdominal assessment revealed no
evidence of disease. The retroperitoneal space noted a 2.5 cm left infrarenal
lymph node and no other abnormal adenopathy on the left side of the aorta. 

PROCEDURE: After obtaining proper consent the patient was taken to the
operating room and prepped and draped in normal sterile fashion in the dorsal
supine position. Vaginal and perineal preparation and a Foley catheter were
placed initially. In the right upper quadrant of the abdomen, a Veress needle
was inserted with placement confirmed by the saline drop test. Pneumoperitoneum was created with 4 L of CO2 gas and then a 5 mm trocar was inserted as well as the laparoscope. Survey of the abdominal cavity revealed no evidence of intraabdominal or peritoneal disease. There were adhesions to her prior midline incision. A 2nd 5 mm port was placed lateral to the first, and then direct observation of the initial port was visualized and was well away from these adhesions and the bowel. Subsequent attention turned to the left flank of the patient and 2 cm cephalad and 2 cm medial to the anterior superior iliac spine, a 3 to 4 cm skin incision was made in this area and taken down the fascia. The fascia was divided approximately 1.5 cm. The surgeon&apos;s finger was then inserted through the rectus muscle into the preperitoneal space. The preperitoneal space was developed over the anterior surface of the psoas muscles and the left iliac artery. Once the space was developed, a blunt trocar was then placed and then a
retropneumoperitoneum was created and the intraperitoneal pneumoperitoneum was evacuated. Subsequently the retroperitoneal space was fully developed to allow for identification of the iliac vessel, left ureter, anterior surface of the psoas muscle. Then additional trocars were placed in the retroperitoneal space under direct visualization including a 5 mm and a 12 mm trocar. Using LigaSure bipolar dissector as well as sealer divider, the full retroperitoneal space was then fully developed to the level of the renal vessels on the left side. The enlarged lymph node that was noted preoperatively was identified and extended up to the level of the renal vein on the left side. The lymph node dissection began at the level of the bifurcation of the aorta and continued cephalad, freeing the enlarged lymph nodes from the lateral surface of the aorta as well as from the medial surface of the patient&apos;s ureter. At approximately 4.5 cm above the inferior mesenteric artery, the boundaries of the enlarged lymph node were identified. It was gently peeled away from the left ovarian vein, azygos
vein, as well as the confluence into the left renal vein. No complications occurred and the specimen was excised at this level. It was then placed in EndoCatch bag for later retrieval. At this point in time then, a left aortic lymph node dissection was then performed from the IMA to the midportion of the common iliac artery on the left side. No complications occurred. These lymph nodes were removed directly through the port. At this point in time, hemostasis was noted. There were no bleeding areas noted from the field of dissection and FloSeal was then placed along the surgical bed along the left side of the aorta in the area of the intrarenal vessels. At this point in time, the pneumoperitoneum was evacuated and the previous lymph node that was placed in an EndoCatch bag, suspicious for metastatic disease was brought out through the balloon trocar port without issue. Subsequently the fascial incision for the blunt trocar was closed with 0 Vicryl in a running continuous fashion. The 5 and 12 mm trocars were then closed with 3-0 Vicryl and Dermabond skin glue. There was noted to be some bleeding from the left 5 mm trocar port. It was opened and re-explored and there was no further bleeding from this area and the bleeding was thought to be controlled. Thus the left flank 5 mm port was reclosed with suture and Dermabond skin glue. At this point in time, the patient was then awakened and taken to the recovery room in stable condition.


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## preserene (Oct 2, 2012)

Infra renal- grouped/come under "para aortic lymph nodes".

The operative note suggest like “Transperitoneal Para-Aortic Lymph Node Dissection (PALN)”.But we do not have a separate code for this alone. There was no pelvic lymphadenectomy carried out. But from the code description“and” can be interpreted  as “ “or”, then the code *38572* is most appropriate; but this is unilateral! could we think of reduces service modifier !

The second option I thought of is *58662.*


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