abozeman
New
Hi - normally when a procedure starts with a laparoscopic approach and converts to open, only the open code is billed. My question is, would this concept apply when the procedure was planned as lap to open since we mostly see an unforeseen circumstance as the reason for a conversion. For the procedure below, the surgeon planned a lap nephrectomy followed by an open approach for the ureterectomy with bladder cuff. Should this be billed as 50236 only or should it be reported some other way (unlisted code, etc). Thank You.
OPERATIVE NOTE
Preoperative Diagnosis: Left upper tract urothelial carcinoma
Postoperative Diagnosis: Left upper tract urothelial carcinoma
Procedure: 1. Left laparoscopic radical nephro ureterectomy with open distal bladder cuff
Specimen:
ID Type Source Tests Collected by Time
1 : Left kidney and ureter Tissue Kidney, Left TISSUE EXAM
Complications: None
Findings: Tumor confined to the kidney, margins grossly negative, good hemostasis at the end of the case
Operative Description:
After informed consent obtained and verified, the patient was taken to the operative room and placed supine on the operating table. Anesthesia was induced by our anesthesia colleagues. After adequate anesthesia and preoperative antibiotics, the patient was then placed in the modified left flank position and prepped and draped in the usual sterile fashion. A surgical timeout was performed.
A Foley catheter was placed. Using standard safety technique I placed a Veress needle in the left upper quadrant. I then placed a 5 French port under direct vision in the left lower quadrant. I then under direct vision placed a 10 port and in the paramedian position and then a 10 port at the site of the Veress needle insertion under direct vision. I now began dissection first by mobilizing the colon off of the retroperitoneum. I also rolled the spleen off the retroperitoneum. This included mobilizing the sigmoid completely off of the retroperitoneum and pelvis. I was then able to isolate the ureter and then marched up the aorta to the level of the renal hilum. The gonadal vein was identified ligated and divided. The gonadal vessels right after they passed over the ureter were identified ligated and divided. A clip was placed on the ureter to prevent tumor spillage. We then worked around the renal hilum until it could be isolated sufficiently to staple across the hilum en bloc with a stapler. We then continued mobilization of the kidney superiorly away from the adrenal gland and off the inferior aspect of the spleen until it was fully mobilized. We checked for hemostasis which appeared to be excellent. We then dissected the ureter further down into the pelvis to facilitate the subsequent bladder cuff. We then looked again for hemostasis which did appear to be excellent. I did place to sets of 0 Vicryl at the 10 ports using a Carter Thompson needle passer. Next we made a low midline incision from below the level of the umbilicus to the pubis. I carried this down through the anterior tissues along the entire course of the incision. The bladder was then mobilized off of the left pelvic sidewall developing the space of Retzius. The peritoneum was divided to store continuity to the previous dissection. The vas deferens was then ligated and divided. The superior vesicle artery was identified ligated and divided. This then allowed me to place a Bookwalter retractor and get excellent exposure. Next I dissected the ureter down to the level of the bladder mucosa. This was done using a combination of electrocautery and the LigaSure as needed. Once I could see the mucosa tenting away from the ureter I placed 2-0 Vicryl's above and below this point into the mucosa and bladder. The ureter was now excised having placed a second clip to prevent spillage. I can clearly see the ureteral orifice which was excised in its entirety. The specimen is now removed. The cystorrhaphy at the location of the ureteral orifice was now closed in 2 layers using running 2-0 Vicryl. I the then we retroperitonealized the area using a running 2-0 Vicryl. We then closed the midline wound after placing a drain through the 5 port site into the pelvis. The wound was closed in a single layer using running looped #1 PDS. We then reinsufflated through the 210 port sites and rechecked for hemostasis which appeared to be excellent. The CO2 was therefore removed from his abdomen and the ports removed and the 0 Vicryl secured. We then closed the subcutaneous tissues with some Vicryl interrupted and then closed all the incisions with staples followed by dressings. Patient was then awoken and taken from the operating room in stable condition. There are no complications.
All instrument and sponge counts were correct x2. At this point, the procedure was finished and the patient was extubated and transferred to PACU in stable condition.
Plan
Plan will be for the patient to the recovery and then to the regular floor. Drain can come out prior to discharge. Patient will maintain the Foley catheter for 2 weeks and return to clinic with a cystogram. Plan will be to get an single dose of intravesical gemcitabine at the time of cystogram.
OPERATIVE NOTE
Preoperative Diagnosis: Left upper tract urothelial carcinoma
Postoperative Diagnosis: Left upper tract urothelial carcinoma
Procedure: 1. Left laparoscopic radical nephro ureterectomy with open distal bladder cuff
Specimen:
ID Type Source Tests Collected by Time
1 : Left kidney and ureter Tissue Kidney, Left TISSUE EXAM
Complications: None
Findings: Tumor confined to the kidney, margins grossly negative, good hemostasis at the end of the case
Operative Description:
After informed consent obtained and verified, the patient was taken to the operative room and placed supine on the operating table. Anesthesia was induced by our anesthesia colleagues. After adequate anesthesia and preoperative antibiotics, the patient was then placed in the modified left flank position and prepped and draped in the usual sterile fashion. A surgical timeout was performed.
A Foley catheter was placed. Using standard safety technique I placed a Veress needle in the left upper quadrant. I then placed a 5 French port under direct vision in the left lower quadrant. I then under direct vision placed a 10 port and in the paramedian position and then a 10 port at the site of the Veress needle insertion under direct vision. I now began dissection first by mobilizing the colon off of the retroperitoneum. I also rolled the spleen off the retroperitoneum. This included mobilizing the sigmoid completely off of the retroperitoneum and pelvis. I was then able to isolate the ureter and then marched up the aorta to the level of the renal hilum. The gonadal vein was identified ligated and divided. The gonadal vessels right after they passed over the ureter were identified ligated and divided. A clip was placed on the ureter to prevent tumor spillage. We then worked around the renal hilum until it could be isolated sufficiently to staple across the hilum en bloc with a stapler. We then continued mobilization of the kidney superiorly away from the adrenal gland and off the inferior aspect of the spleen until it was fully mobilized. We checked for hemostasis which appeared to be excellent. We then dissected the ureter further down into the pelvis to facilitate the subsequent bladder cuff. We then looked again for hemostasis which did appear to be excellent. I did place to sets of 0 Vicryl at the 10 ports using a Carter Thompson needle passer. Next we made a low midline incision from below the level of the umbilicus to the pubis. I carried this down through the anterior tissues along the entire course of the incision. The bladder was then mobilized off of the left pelvic sidewall developing the space of Retzius. The peritoneum was divided to store continuity to the previous dissection. The vas deferens was then ligated and divided. The superior vesicle artery was identified ligated and divided. This then allowed me to place a Bookwalter retractor and get excellent exposure. Next I dissected the ureter down to the level of the bladder mucosa. This was done using a combination of electrocautery and the LigaSure as needed. Once I could see the mucosa tenting away from the ureter I placed 2-0 Vicryl's above and below this point into the mucosa and bladder. The ureter was now excised having placed a second clip to prevent spillage. I can clearly see the ureteral orifice which was excised in its entirety. The specimen is now removed. The cystorrhaphy at the location of the ureteral orifice was now closed in 2 layers using running 2-0 Vicryl. I the then we retroperitonealized the area using a running 2-0 Vicryl. We then closed the midline wound after placing a drain through the 5 port site into the pelvis. The wound was closed in a single layer using running looped #1 PDS. We then reinsufflated through the 210 port sites and rechecked for hemostasis which appeared to be excellent. The CO2 was therefore removed from his abdomen and the ports removed and the 0 Vicryl secured. We then closed the subcutaneous tissues with some Vicryl interrupted and then closed all the incisions with staples followed by dressings. Patient was then awoken and taken from the operating room in stable condition. There are no complications.
All instrument and sponge counts were correct x2. At this point, the procedure was finished and the patient was extubated and transferred to PACU in stable condition.
Plan
Plan will be for the patient to the recovery and then to the regular floor. Drain can come out prior to discharge. Patient will maintain the Foley catheter for 2 weeks and return to clinic with a cystogram. Plan will be to get an single dose of intravesical gemcitabine at the time of cystogram.