lcole7465
Expert
I'm going back and forth between 50545 and 50546 on this one. Because they discontinued the lymph node dissection I want 50545-52. Another coder is saying it should be 50546.
Any thought from the urology coders out there???
Abdomen prepped appears fashion. Incision was made off of the umbilicus toward the right paramedian side. Veress needle used to enter the peritoneal cavity. Saline drop test performed. Remaining ports directly visualized in. Four views. Also 2 assistant ports.
*
The colon was reflected along the line of Toldt. The liver attachments the paddle renal ligaments were released. The liver was retracted superiorly using a locking grasper. To the sidewall.
*
Given the position in the duodenum fell off of the cava did not need to be dissected. The high ureter was identified carried up proximally. The gonadal vein was kept medial. I incised the overlying tissue over the vena cava. Yet obvious lymphadenopathy at the hilum. Intimately associated with the large hilar vessels with renal vein as well as the renal artery. I was able to dissect free 2 renal veins and 1 renal artery. I initially controlled them with silk ties given the backstop of the lymph node mass in the hilum abd underneath the vena cava. I tied the artery 1st and then the 2 veins. This allowed me further freedom to dissect along these vessels in order to then gain access for a stapler. All 3 were individually stapled.
*
I then had better visualization of the lymph node involvement. It was extensive at the hilum. There is also a separate lymph node inferiorly close to the large dominant 1. The length of the lymph node in the axial plane was about 5- 6 cm. The lymph node mass was exceedingly vascular. I was dissecting on the vena cava just to try to gain some access between the cava and the lymph node packet inferior margin bleeding was encountered. I put a rolled raytec on this area with the 4th arm. I left the pressure on this with the 4th arm locked in place and there was good hemostasis I then went ahead and completed the nephrectomy.
*
I review the MRI. The adrenal gland was well out of the way of the mass. I spared the adrenal gland. I used the vessel sealer shears as well as combination of scissors and bipolar in order to release the kidney superiorly inferiorly and laterally. I then used Weck clips to control the ureter. Specimen was now freed.
*
I then turned my intention to that area of the bleeding. I lifted up the Ray-Tec still had some bleeding there but not too bad a used for Prolene figure-of-eight onto the vena cava where a small perforating vessel was in countered in had some bleeding therefore tied it and there was excellent hemostasis.
*
*
I then began dissecting out the lymph node mass. It became readily apparent that this mass was hypervascular. Surprisingly even the small little intervening tissue that I engaged with bipolar would bleed despite good bipolar. This obscured visualization significantly. It was very disconcerting not being able to release the mass from the vena cava in order to identify the perforating vessels. I was able to identify a few and controlled them with Weck clips or silk ties. But every time I went to release further I would get bleeding that was surprising bleeding and speaks to the hypervascular nature of the mass. Also the mass had right off of the renal vein a large vessel (close to the size of the renal vein) diving down into the mass. Renal artery also had several apparent feeders into this mass coming off of hard to get to angles. Dissecting around these areas would also stir some bleeding- with the mass encasing the vessels not allowing dissection in order to place clips.
*
After working for upwards close to 2.5 hr very little progress was made. Unfortunately I I felt it was in the best interest of the patient to cease lymph node dissection has this has been deemed unresectable.
*
This point we placed some Gel-Foam over the area of the lymph node tumor in the hilum. We then directly visualized the ports after undocking the robot. We then opened up assistant port in the midline brought the specimen out. Close the fascia using running Vicryl suture 1. Switched on both sides. Wounds were copiously irrigated. Skin was closed with Monocryl.
Any thought from the urology coders out there???
Abdomen prepped appears fashion. Incision was made off of the umbilicus toward the right paramedian side. Veress needle used to enter the peritoneal cavity. Saline drop test performed. Remaining ports directly visualized in. Four views. Also 2 assistant ports.
*
The colon was reflected along the line of Toldt. The liver attachments the paddle renal ligaments were released. The liver was retracted superiorly using a locking grasper. To the sidewall.
*
Given the position in the duodenum fell off of the cava did not need to be dissected. The high ureter was identified carried up proximally. The gonadal vein was kept medial. I incised the overlying tissue over the vena cava. Yet obvious lymphadenopathy at the hilum. Intimately associated with the large hilar vessels with renal vein as well as the renal artery. I was able to dissect free 2 renal veins and 1 renal artery. I initially controlled them with silk ties given the backstop of the lymph node mass in the hilum abd underneath the vena cava. I tied the artery 1st and then the 2 veins. This allowed me further freedom to dissect along these vessels in order to then gain access for a stapler. All 3 were individually stapled.
*
I then had better visualization of the lymph node involvement. It was extensive at the hilum. There is also a separate lymph node inferiorly close to the large dominant 1. The length of the lymph node in the axial plane was about 5- 6 cm. The lymph node mass was exceedingly vascular. I was dissecting on the vena cava just to try to gain some access between the cava and the lymph node packet inferior margin bleeding was encountered. I put a rolled raytec on this area with the 4th arm. I left the pressure on this with the 4th arm locked in place and there was good hemostasis I then went ahead and completed the nephrectomy.
*
I review the MRI. The adrenal gland was well out of the way of the mass. I spared the adrenal gland. I used the vessel sealer shears as well as combination of scissors and bipolar in order to release the kidney superiorly inferiorly and laterally. I then used Weck clips to control the ureter. Specimen was now freed.
*
I then turned my intention to that area of the bleeding. I lifted up the Ray-Tec still had some bleeding there but not too bad a used for Prolene figure-of-eight onto the vena cava where a small perforating vessel was in countered in had some bleeding therefore tied it and there was excellent hemostasis.
*
*
I then began dissecting out the lymph node mass. It became readily apparent that this mass was hypervascular. Surprisingly even the small little intervening tissue that I engaged with bipolar would bleed despite good bipolar. This obscured visualization significantly. It was very disconcerting not being able to release the mass from the vena cava in order to identify the perforating vessels. I was able to identify a few and controlled them with Weck clips or silk ties. But every time I went to release further I would get bleeding that was surprising bleeding and speaks to the hypervascular nature of the mass. Also the mass had right off of the renal vein a large vessel (close to the size of the renal vein) diving down into the mass. Renal artery also had several apparent feeders into this mass coming off of hard to get to angles. Dissecting around these areas would also stir some bleeding- with the mass encasing the vessels not allowing dissection in order to place clips.
*
After working for upwards close to 2.5 hr very little progress was made. Unfortunately I I felt it was in the best interest of the patient to cease lymph node dissection has this has been deemed unresectable.
*
This point we placed some Gel-Foam over the area of the lymph node tumor in the hilum. We then directly visualized the ports after undocking the robot. We then opened up assistant port in the midline brought the specimen out. Close the fascia using running Vicryl suture 1. Switched on both sides. Wounds were copiously irrigated. Skin was closed with Monocryl.