# Excision of Pheochromocytoma



## myelsik (Mar 12, 2015)

Hello! I'm a little stuck on this surgery, as it is listed in the description as being an open left adrenalectomy, although as you can see from the following op note, this is clearly not all there is to this.  I used 239.7 as my dx, as it is not yet specified whether the pheochromocytoma is malignant or benign. Any thoughts would be greatly appreciated!

POSTOPERATIVE DIAGNOSIS:
Left adrenal pheochromocytoma.

OPERATION: 
Left open adrenalectomy.
OPERATIVE PROCEDURE:
The patient was taken to the operating room, and after adequate induction of general anesthetic was placed in the supine position.  A Foley catheter was placed into the bladder with sterile technique.  An art line was placed per Anesthesia.  She was then placed in a 45-degree semi-flank position with a gel bolster behind her back and axillary roll in place and all extremities well padded.  The table was flexed.  The left flank was elevated.  She was secured to the table with tape and beanbag.  The left arm was secured at her side.  She was rotated side to side with good stability.  The abdomen was prepped and draped in the usual sterile fashion.  A small mid abdominal paramedian incision was then made for the camera port.  Dissection was carried down to the fascia and the fascia incised.  Finger dissection intra-abdominally appeared to show no evidence of adhesions towards the left kidney.  A 12 mm Hasson port was then placed and subsequent visualization with the 30-degree up camera, demonstrated a very confined visual field, which was felt to definitely preclude continuing robotically.   

At this point, an extended left subcostal incision was then made and dissection carried through the subcutaneum using electrocautery.  The anterior rectus fascia was incised.  The left rectus muscles were divided using electrocautery.  The posterior rectus sheath and peritoneum were divided, and the abdomen entered.  The remainder of the flank incision was then opened using electrocautery.  A Bookwalter self-retaining retractor was utilized.  The left colon was then mobilized over Gerota fascia, exposing the upper half of the left kidney and adrenal gland.  The previously noted left adrenal nodule was visualized and appeared to be quite superficial to the adrenal gland.  For this reason, it was felt prudent to just excise the pheochromocytoma and leave the remainder of the adrenal gland intact.  This was accomplished between titanium clips with good hemostasis.  The tumor was excised with a small rim of normal adrenal gland and perinephric tissue.  The remainder of the adrenal gland was inspected visually and manually, and there was no other evidence of further nodularities or abnormalities.  Hemostasis was adequate.  The wound was copiously irrigated.  FloSeal was applied in this area as well as Surgicel.  The fascia and musculature were then reapproximated in layers using running 0 Vicryl.  Skin was reapproximated with staples.  Dry sterile dressings were applied, and the procedure was terminated.  The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.


**I am thinking 60545, as I cannot seem to get any more specific with the tumor, however I am not quite sure if this reads as a partial adrenalectomy with only a "small rim of regular adrenal gland and perinephric tissue"; does the "small rim" qualify as a partial? Please help!


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## emcee101 (Mar 13, 2015)

mwilk, 

Take a look at CPT range 49203-49205 which index to open excision of retroperitoneal tumors. it may more accurately describe the procedure performed, and I think the reimbursement will also be more favorable as well


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## Kelly_Mayumi (Mar 18, 2015)

What did the pathology return?


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## mitchellde (Mar 18, 2015)

The CPT instructs you to use the 49203-49205 codes for remote pheochromocytoma.  This was not described as remote.  The 60540 looks the best to me.  The tumor was part of the adrenal gland but it was found to be superficial so it could be removed along with only the very rim of the adrenal rather than having to remove the entire organ as the surgeon originally thought.


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