I know the adrenalectomy would be included in 50545, but is it appropriate to report separately with 50548? Thanks!!
Indications: procedure for Malignant neoplasm of left renal pelvis
Procedure Details: Patient was properly identified and brought back to the operating suite. He was placed supine on the operating table. Under the direction of Anesthesiology, he was induced under general anesthetic. A proper time-out was performed. Ancef 2 g IV were given. A 16 French Foley catheter was placed by the nursing staff and light pink urine returned. He was placed in right lateral decubitus position. All pressure points were padded. He was was appropriately flexed and prepped and draped in normal sterile surgical fashion. A stab incision was made just superior and lateral to the umbilicus on the patient's left side, triangulated between the xiphoid process and the 11th rib. A Veress needle was carefully passed into the abdominal cavity. Its proper position was confirmed. We began insufflation and pneumoperitoneum was easily achieved. Under direct visualization, I passed a 8 mm robotic trocar into abdominal cavity. The abdominal Cavity was carefully inspected and there was no evidence of any intra-abdominal bleeding or injury to other abdominal organs. At this point for the ports were placed all under direct visualization. This included an 8 mm robotic port in the left upper quadrant a 12 mm robotic port in the left lower quadrant a 10 mm assistant port in the midline superior to the umbilicus and in another 8 mm robotic port across the midline on the right side of the abdomen approximately 2 fingerbreadths above the pubic symphysis. The robot was docked on the patient's left side. At this time, I noticed that the patient's: Was located on the lateral aspect of his kidney as the kidney could clearly be seen. However I did reflect the colon medially by taking down the white line of Toldt. This exposed the proper planes. Once the colon was reflected, I was able to easily identify the gonadal vein and ureter inferiorly. A robotic hemo lock clip was used to clamp off the Ureter. I followed the gonadal vein into its insertion of the left renal vein. The gonadal vein was divided and ligated with the robotic vessel sealer. The patient had a significant amount of lymphatics around his hilum which were controlled with bipolar electrocautery. Once I dissected out the vein circumferentially was able to list find the singular renal artery as well. The robotic stapler was used to divide the renal artery followed by a separate staple load to divide the renal vein. The staple lines appeared to be intact and hemostatic. At this point I dissected the superior and lateral attachments to further mobilize the kidney, Including the left adrenal gland which also had a mass that was visualized corresponding to recent CT of the chest findings. Once the kidney and ureter were completely mobilized medially superior and laterally I focused my attention on dissecting out the rest of the ureter down to the bladder. This dissection went quite well as the ureter was not adherent and dissected without difficulty past the iliac vessels all the way down to the insertion of the bladder. I dissected out the intramural ureter. A robotic clip applier was then used to place a clip across the distal ureter. Once this was complete, I created my bladder cuff and dissected out the rest the ureter leaving a small hole in the bladder itself. The left adrenal gland kidney and ureter were placed in the lower pelvis for later extraction. The renal fossa was copiously irrigated, and there was no active bleeding seen. The renal hilum and spleen appear to be intact. Both Arista and this Tisseel were used to reinforce hemostasis both in the pelvis and around the renal fossa. This was done after the intra-abdominal pressure was brought down to 7 mmHg. At this point, the specimen was placed in the Endo-Catch bag was extracted through the left lower quadrant incision after extending the incision. Incision was closed in 2 layers 1st the peritoneum with a running 0 Vicryl followed by the fascia with a looped PDS. A 15 French JP drain was placed through the right lower robotic port. And secured with a 3-0 nylon. A 2nd look was performed with the robotic camera. No bleeding was noted along the hilum spleen or renal fossa area. The pelvis was inspected as well and there was no bleeding seen here either as the external iliac artery was pulsating. The extraction incision was inspected and was free of any bowel attachments underneath. At this point the remaining ports removed under direct visualization the skin incisions were closed with Monocryl and Dermabond. This concluded procedure. The sponge instrument and needle count was correct at the end the case. Estimated blood loss 100 ml. Patient was extubated and sent to recovery in stable condition without immediate complications. RP 20220505
Indications: procedure for Malignant neoplasm of left renal pelvis
Procedure Details: Patient was properly identified and brought back to the operating suite. He was placed supine on the operating table. Under the direction of Anesthesiology, he was induced under general anesthetic. A proper time-out was performed. Ancef 2 g IV were given. A 16 French Foley catheter was placed by the nursing staff and light pink urine returned. He was placed in right lateral decubitus position. All pressure points were padded. He was was appropriately flexed and prepped and draped in normal sterile surgical fashion. A stab incision was made just superior and lateral to the umbilicus on the patient's left side, triangulated between the xiphoid process and the 11th rib. A Veress needle was carefully passed into the abdominal cavity. Its proper position was confirmed. We began insufflation and pneumoperitoneum was easily achieved. Under direct visualization, I passed a 8 mm robotic trocar into abdominal cavity. The abdominal Cavity was carefully inspected and there was no evidence of any intra-abdominal bleeding or injury to other abdominal organs. At this point for the ports were placed all under direct visualization. This included an 8 mm robotic port in the left upper quadrant a 12 mm robotic port in the left lower quadrant a 10 mm assistant port in the midline superior to the umbilicus and in another 8 mm robotic port across the midline on the right side of the abdomen approximately 2 fingerbreadths above the pubic symphysis. The robot was docked on the patient's left side. At this time, I noticed that the patient's: Was located on the lateral aspect of his kidney as the kidney could clearly be seen. However I did reflect the colon medially by taking down the white line of Toldt. This exposed the proper planes. Once the colon was reflected, I was able to easily identify the gonadal vein and ureter inferiorly. A robotic hemo lock clip was used to clamp off the Ureter. I followed the gonadal vein into its insertion of the left renal vein. The gonadal vein was divided and ligated with the robotic vessel sealer. The patient had a significant amount of lymphatics around his hilum which were controlled with bipolar electrocautery. Once I dissected out the vein circumferentially was able to list find the singular renal artery as well. The robotic stapler was used to divide the renal artery followed by a separate staple load to divide the renal vein. The staple lines appeared to be intact and hemostatic. At this point I dissected the superior and lateral attachments to further mobilize the kidney, Including the left adrenal gland which also had a mass that was visualized corresponding to recent CT of the chest findings. Once the kidney and ureter were completely mobilized medially superior and laterally I focused my attention on dissecting out the rest of the ureter down to the bladder. This dissection went quite well as the ureter was not adherent and dissected without difficulty past the iliac vessels all the way down to the insertion of the bladder. I dissected out the intramural ureter. A robotic clip applier was then used to place a clip across the distal ureter. Once this was complete, I created my bladder cuff and dissected out the rest the ureter leaving a small hole in the bladder itself. The left adrenal gland kidney and ureter were placed in the lower pelvis for later extraction. The renal fossa was copiously irrigated, and there was no active bleeding seen. The renal hilum and spleen appear to be intact. Both Arista and this Tisseel were used to reinforce hemostasis both in the pelvis and around the renal fossa. This was done after the intra-abdominal pressure was brought down to 7 mmHg. At this point, the specimen was placed in the Endo-Catch bag was extracted through the left lower quadrant incision after extending the incision. Incision was closed in 2 layers 1st the peritoneum with a running 0 Vicryl followed by the fascia with a looped PDS. A 15 French JP drain was placed through the right lower robotic port. And secured with a 3-0 nylon. A 2nd look was performed with the robotic camera. No bleeding was noted along the hilum spleen or renal fossa area. The pelvis was inspected as well and there was no bleeding seen here either as the external iliac artery was pulsating. The extraction incision was inspected and was free of any bowel attachments underneath. At this point the remaining ports removed under direct visualization the skin incisions were closed with Monocryl and Dermabond. This concluded procedure. The sponge instrument and needle count was correct at the end the case. Estimated blood loss 100 ml. Patient was extubated and sent to recovery in stable condition without immediate complications. RP 20220505
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