emilyadams1993@yahoo.com
Guest
PROCEDURE:
Radical Cystectomy.
Radical Prostatectomy.
Ileal Conduit urinary diversion.
Bilateral ureteral stents placements.
INDICATIONS:
53 y.o. male with history of invasive bladder cancer into the bladder, status post colon resection with partial cystectomy and bilateral ureteral reimplant, unfortunatly the patient had recurrence in the rectal stum Invading into the bladder. The patient was consented for total pelvic exenteration. I explained to the patient that a cystectomy is a major operation to remove the bladder. In men, the bladder, prostate, seminal vesicles and lymph nodes are removed. In women, the bladder, urethra, part of the vagina and lymph nodes are removed. In addition, the uterus, fallopian tubes and ovaries may be removed. I explained that possible post operative complications. Overall 65% of patient will have a complication such as but not only, infection, bleeding, bowel obstruction, bowel leakage, erectile dysfunction in males, cardiovascular, pulmonary and clotting complications. Most of these complications are low grade complications and about 13% having high grade complications. And the risk of death is around 3% within the first 3 months after surgery.
FINDINGS:
Large pelvic mass invading into the posterior wall of the bladder, the sacrum, the posterior pelvic wall all the way to the hypogastric vessels. Complete resection was impossible. There was extreme desmoplastic reaction all around the pelvis. It was very difficult to identify the ureters. Both were scared down to the sacrum. The fibrosis was so extreme that we had very difficult time identified the external iliac veins. We certainly were not able to identify the obturator nerves. The posterior dissection was very hard. We could not separate the mass from the sacrum. The grossly residual tumor was noticed. This extended to both pedicals and the posterior side.
DRAINS:
2 x 8 Fr feeding tumor JP drain.
PROCEDURE:
After informed consent was obtained, the patient was brought to the operative table and placed in supine position. Intravenous antibiotics were administered. After successful induction of general anesthesia with endo tracheal intubation without difficulty, sequential compression device were placed on lower extremities. The patient was repositioned into a modified dorsal lithotomy position with Allen stir ups. All pressure points were padded adequately.
The patient was prepped and draped in standard sterile fashion. 20 French urinary catheter was placed in sterile condition, the ballon was inflated with 30cc sterile water. and placed to gravity drainage. Surgery was started by Colo rectal surgery. They mobilized the small bowel. The bladder was mobilized. There was severe fibrosis anteriority. We had to use the bovie to drop the bladder and open the endopelvic fascia. The latter dissection was difficult both side. After tedious work we were able to identify the external iliac arteries and follow them to the common iliacs. The right ureter was identified as it coursed deeply into the pelvis. There was severe fibrosis around both distal ureters. We were able to dissect superiorly to what looked to be healthier tissue. Vesseloop was used to isolate the ureters and help dissecting it. The dissection was carried all the way to the bladder wall and superiorly above the pelvic rim. All vessels were cauterized or clipped. The ureter was then clipped with a large clip proximally and tied with a zero silk ligature distally and divided with scissors.
The bowel was then packed on the abdominal wall. The cul-de-sac was then opened and a plane was created between the sacrum and the bladder and mass. The lateral vascular pedicles were identified and taken down to the level of the pelvic floor with Ligasure. It was clear that we have cancer on the hypogastric vessels. The tissue was extremely hard and dissection was difficult. During the same time the general surgeons started the posterior dissection and freeing the rectum posteriorly and laterally stapling device with vascular clips. The levators were brushed laterally using the peanut. The superficial vein complex was controlled with the Ligasure. The dorsal vein complex was then bunched over the back of the anterior prostate with the endopelvic fascia using a Babcock clamp and black bleeding suture was placed with 0 Vicryl in a figure of 8. The dorsal vein complex was then isolated with a right angel clamp anterior to the urethra. 0 Vicryl tie and a figure of 8 suture was placed around the DVC and secured to the periosteum of the pubis symphysis. The DVC was then dissected sharply with bovie. The DVC was then secured with a 2-0 Vicryl suture in a running fashion and tied to the pubis periosteum. This exposed the apex of the prostate. The anterior uretheral was then transected with scissors. The Foley catheter was then clamped to prevent any spillage of urine and brought to the surgical cavity. The prostate was then retracted superiorly, the anus, bladder, prostate, rectum and the mass were taken in one piece.
The surgical fossa was copiously irrigated with sterile water and inspected for any active bleeding and meticulous hemostasis was obtained.
General surgery team close the perineal incision as per their note.
Attention was then turned to the formation of the ileal conduit. Approximately 12-15 cm of ileum was isolated about 20 cm from the ileocecal valve. This was longer than usual to reach the retroperitoneum since the ureteral stumps were very short, the anastomosis was difficult but went well. Mesenteric windows were made in the usual fashion using Ligasure, then the bowel was divided with an Endo-GIA stapler. The small bowel continuity was restored in a side to side fashion using the end GIA 80 and the TA 90 staplers. The anastomosis was widely patent and there was no evidence of ischemia or leakage. The ends of the staple line were covered with mesenteric fat using 3-0 silk sutures. The crotch of the anastomosis was secured and the mesenteric trap was closed with interrupted 3-0 silk sutures.
Both ureters were implanted into the proximal end of the ileal conduit over 8 French feeding tubes in a Bricker type fashion using interrupted 4-0 Vicryl sutures. Both ureters were tacked to the conduit with 5-0 silk sutures. The conduit was then filled with a sterile saline solution both ureters freely refluxed and there was no evidence of leakage from the anastomoses.
Attention was then turned to formation of the stoma. A previously selected site in the right lower quadrant was utilized. A circle of skin was removed using the skin knife and then the subcutaneous fat was spread down to the fascia which was opened in a cruciate fashion. The rectus muscle was spread using Kelly clamps and then the conduit was brought through the abdominal wall taking care not to torque the mesentery. The stoma was matured in a rose bud type fashion after tacking the stoma to the fascia with four interrupted Vicryl sutures to prevent peristoma hernia. The stents were secured in place with drain sutures. The abdomen was reinspected for hemostasis, the bowel was run from the small bowl anastomosis to the ligament of Trietz and replaced in its normal position the bowel was covered with omentum. The abdomen was closed with 0 Maxon loop in a running fashion of the fascia. The wound was irrigated with sterile saline. The skin was closed with staples. A telfa gauze dressing was applied to the incision. Patient was discharge from the OR in a stable condition.
How would you code this? ????
For urology portion.
Radical Cystectomy.
Radical Prostatectomy.
Ileal Conduit urinary diversion.
Bilateral ureteral stents placements.
INDICATIONS:
53 y.o. male with history of invasive bladder cancer into the bladder, status post colon resection with partial cystectomy and bilateral ureteral reimplant, unfortunatly the patient had recurrence in the rectal stum Invading into the bladder. The patient was consented for total pelvic exenteration. I explained to the patient that a cystectomy is a major operation to remove the bladder. In men, the bladder, prostate, seminal vesicles and lymph nodes are removed. In women, the bladder, urethra, part of the vagina and lymph nodes are removed. In addition, the uterus, fallopian tubes and ovaries may be removed. I explained that possible post operative complications. Overall 65% of patient will have a complication such as but not only, infection, bleeding, bowel obstruction, bowel leakage, erectile dysfunction in males, cardiovascular, pulmonary and clotting complications. Most of these complications are low grade complications and about 13% having high grade complications. And the risk of death is around 3% within the first 3 months after surgery.
FINDINGS:
Large pelvic mass invading into the posterior wall of the bladder, the sacrum, the posterior pelvic wall all the way to the hypogastric vessels. Complete resection was impossible. There was extreme desmoplastic reaction all around the pelvis. It was very difficult to identify the ureters. Both were scared down to the sacrum. The fibrosis was so extreme that we had very difficult time identified the external iliac veins. We certainly were not able to identify the obturator nerves. The posterior dissection was very hard. We could not separate the mass from the sacrum. The grossly residual tumor was noticed. This extended to both pedicals and the posterior side.
DRAINS:
2 x 8 Fr feeding tumor JP drain.
PROCEDURE:
After informed consent was obtained, the patient was brought to the operative table and placed in supine position. Intravenous antibiotics were administered. After successful induction of general anesthesia with endo tracheal intubation without difficulty, sequential compression device were placed on lower extremities. The patient was repositioned into a modified dorsal lithotomy position with Allen stir ups. All pressure points were padded adequately.
The patient was prepped and draped in standard sterile fashion. 20 French urinary catheter was placed in sterile condition, the ballon was inflated with 30cc sterile water. and placed to gravity drainage. Surgery was started by Colo rectal surgery. They mobilized the small bowel. The bladder was mobilized. There was severe fibrosis anteriority. We had to use the bovie to drop the bladder and open the endopelvic fascia. The latter dissection was difficult both side. After tedious work we were able to identify the external iliac arteries and follow them to the common iliacs. The right ureter was identified as it coursed deeply into the pelvis. There was severe fibrosis around both distal ureters. We were able to dissect superiorly to what looked to be healthier tissue. Vesseloop was used to isolate the ureters and help dissecting it. The dissection was carried all the way to the bladder wall and superiorly above the pelvic rim. All vessels were cauterized or clipped. The ureter was then clipped with a large clip proximally and tied with a zero silk ligature distally and divided with scissors.
The bowel was then packed on the abdominal wall. The cul-de-sac was then opened and a plane was created between the sacrum and the bladder and mass. The lateral vascular pedicles were identified and taken down to the level of the pelvic floor with Ligasure. It was clear that we have cancer on the hypogastric vessels. The tissue was extremely hard and dissection was difficult. During the same time the general surgeons started the posterior dissection and freeing the rectum posteriorly and laterally stapling device with vascular clips. The levators were brushed laterally using the peanut. The superficial vein complex was controlled with the Ligasure. The dorsal vein complex was then bunched over the back of the anterior prostate with the endopelvic fascia using a Babcock clamp and black bleeding suture was placed with 0 Vicryl in a figure of 8. The dorsal vein complex was then isolated with a right angel clamp anterior to the urethra. 0 Vicryl tie and a figure of 8 suture was placed around the DVC and secured to the periosteum of the pubis symphysis. The DVC was then dissected sharply with bovie. The DVC was then secured with a 2-0 Vicryl suture in a running fashion and tied to the pubis periosteum. This exposed the apex of the prostate. The anterior uretheral was then transected with scissors. The Foley catheter was then clamped to prevent any spillage of urine and brought to the surgical cavity. The prostate was then retracted superiorly, the anus, bladder, prostate, rectum and the mass were taken in one piece.
The surgical fossa was copiously irrigated with sterile water and inspected for any active bleeding and meticulous hemostasis was obtained.
General surgery team close the perineal incision as per their note.
Attention was then turned to the formation of the ileal conduit. Approximately 12-15 cm of ileum was isolated about 20 cm from the ileocecal valve. This was longer than usual to reach the retroperitoneum since the ureteral stumps were very short, the anastomosis was difficult but went well. Mesenteric windows were made in the usual fashion using Ligasure, then the bowel was divided with an Endo-GIA stapler. The small bowel continuity was restored in a side to side fashion using the end GIA 80 and the TA 90 staplers. The anastomosis was widely patent and there was no evidence of ischemia or leakage. The ends of the staple line were covered with mesenteric fat using 3-0 silk sutures. The crotch of the anastomosis was secured and the mesenteric trap was closed with interrupted 3-0 silk sutures.
Both ureters were implanted into the proximal end of the ileal conduit over 8 French feeding tubes in a Bricker type fashion using interrupted 4-0 Vicryl sutures. Both ureters were tacked to the conduit with 5-0 silk sutures. The conduit was then filled with a sterile saline solution both ureters freely refluxed and there was no evidence of leakage from the anastomoses.
Attention was then turned to formation of the stoma. A previously selected site in the right lower quadrant was utilized. A circle of skin was removed using the skin knife and then the subcutaneous fat was spread down to the fascia which was opened in a cruciate fashion. The rectus muscle was spread using Kelly clamps and then the conduit was brought through the abdominal wall taking care not to torque the mesentery. The stoma was matured in a rose bud type fashion after tacking the stoma to the fascia with four interrupted Vicryl sutures to prevent peristoma hernia. The stents were secured in place with drain sutures. The abdomen was reinspected for hemostasis, the bowel was run from the small bowl anastomosis to the ligament of Trietz and replaced in its normal position the bowel was covered with omentum. The abdomen was closed with 0 Maxon loop in a running fashion of the fascia. The wound was irrigated with sterile saline. The skin was closed with staples. A telfa gauze dressing was applied to the incision. Patient was discharge from the OR in a stable condition.
How would you code this? ????
For urology portion.