sandy06
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PREOPERATIVE DIAGNOSIS:
1. Squamous cell carcinoma of the middle esophagus.
2. Esophageal obstruction with odynophagia.
POSTOPERATIVE DIAGNOSIS:
1. Squamous cell carcinoma of the middle esophagus.
2. Esophageal obstruction with odynophagia.
PROCEDURE PERFORMED:
1. Laparoscopically robotic minimally invasive thoracoabdominal near
total esophagectomy with intrathoracic gastroesophageal
anastomosis.
2. Laparoscopic placement of feeding jejunostomy.
3. Retroperitoneal lymph node dissection.
4. Mediastinal lymph node dissection.
SURGEON:
Dr. L (surgical oncology).
CO-SURGEON:
Dr. W (thoracic surgery)
FIRST ASSISTANT:
S, M.D.
SECOND ASSISTANT:
B., PA-C.
ANESTHESIA:
General endotracheal.
ATTENDING ANESTHESIOLOGIST:
Dr. K.
ESTIMATED BLOOD LOSS:
300 mL.
COMPLICATIONS:
None.
SPECIMENS REMOVED:
1. Distal 2/3 of the esophagus and proximal stomach with attached
mediastinal and retroperitoneal lymph nodes. The specimen also
contained the lymph nodes of the lesser curvature.
2. Anastomotic donuts from the esophagogastric anastomosis. By frozen
section, the initial margin of resection was positive for
infiltrating squamous cell carcinoma. However, the second and
final margin from the tissue donuts was negative for malignancy.
JUSTIFICATION FOR THE PROCEDURE:
Mr. V. is a 82-year-old male that was admitted to
Hospital through the emergency room yesterday after visiting
the office of Dr. W. The patient has mid esophageal cancer
that has produced complete obstruction and has been diagnosed by
biopsy as a squamous cell carcinoma. The patient has had restaging
studies with CT scan of the chest, abdomen, and pelvis and there is
no evidence by imaging of metastatic disease.
With these findings, the patient comes for minimally invasive near
total esophagectomy.
FINDINGS:
In the abdominal part of the procedure, there was no evidence of
disseminated disease in the abdomen. The liver appeared to be free of
metastases and the lymph nodes in the retroperitoneum as well as the
lesser curvature did not appear to contain metastatic disease. In the
mediastinum, the most significant finding was the tumor immediately
adjacent and adherent to the pericardium. The lymph nodes did not
appear to be grossly enlarged but were firm and fibrotic consistent
with either metastatic disease or desmoplastic reaction. Once the
procedure was completed, all gross evidence of disease had been
removed. There was no gross evidence of residual disease.
INFORMED CONSENT:
In the holding area before the patient was brought to the operating
room, the patient signed an informed written consent, after myself
and Dr. W. explained to him in detail the purpose of the
procedure, the risks associated with the surgery. The risks quoted to
the patient included anastomotic leak, injury to intra-abdominal or
thoracic structures, bleeding, infection, and complications related
to general endotracheal anesthesia such as deep vein thrombosis,
pulmonary emboli, and cardiac complications.
PATIENT IDENTIFICATION:
In the operating room, before the procedure was started, we took a
"time-out" to properly identify the patient by name, as well as
intended surgical procedure. Once the nurse anesthetist and the
circulating nurse agreed with the proper identification of the
patient, and intended surgical procedure, the operation was started
as described below.
PROCEDURE IN DETAIL:
The patient was placed supine on the operating table and after
satisfactory general endotracheal anesthesia, the anterior abdominal
wall was prepared sterile with Betadine solution and draped
sterilely. We then proceeded to make an incision above the umbilicus
through which a Veress needle was introduced and the pneumoperitoneum
was achieved. Once the pneumoperitoneum was achieved, we proceeded to
place 3 additional 8 mm trocars; the first one was located in the
left upper quadrant; the second one in the right upper quadrant; the
3rd one was in the left flank. We then introduced a 0.5 accessory
trocar in the left lower quadrant. During the case, a 5 mm trocar was
added to service an accessory port also in the right upper quadrant.
Once the trocars were in place, we docked the da Vinci robot. We
used a 30 degree camera looking down and the right arm, arm number
one, we used monopolar shears and arm number two on the left side, we
used a bipolar fenestrated grasper, and then arm number three on the
right side we used the ProGrasp grasper. We started by identifying
the last branch of the gastroepiploic artery and transecting the
greater omentum at this level. We then proceeded to transect the
short gastric vessels and cauterizing. We used the LigaSure
instrument for this purpose. Once we reached the fundus of the
stomach, we turned our attention to the lesser curvature. The
gastrohepatic ligament was incised using the shears next to the liver
and then continued cephalad until the gastroesophageal junction was
identified. The lymph node dissection from the lesser curvature was
carried out using the LigaSure instrument until we reached the
gastroesophageal junction where the lymph nodes were left attached to
the specimen. The left and right crus of the diaphragm were
identified and dissected with the monopolar shears. We then proceeded
to dissect the mediastinum all the way to the junction of the middle
3rd with the lower 3rd of the esophagus. After this dissection was
completed, we then proceeded to separate the posterior gastric wall
from the anterior pancreatic wall until we found the left gastric
artery. The left gastric artery was stapled and transected with a
purple Endo-GIA 60 mm. Once the left gastric artery was transected,
we proceeded to dissect the pylorus in order to mobilize it and
verify that it could reach the right crus of the diaphragm. Once this
was accomplished, we introduced an Intra-jet device through one of
the trocars and through the Intra-jet device, we injected the pylorus
for a chemical pyloroplasty. A total of 4 mL of the solution that
contained 100 units of Botox was injected into the pylorus. Once this
was accomplished, we proceeded to do the feeding jejunostomy. We
tacked the proximal jejunum 20 cm from the ligament of Treitz to the
anterior abdominal wall. We then used a needle jejunostomy to
puncture the jejunum and verified that we were inside the lumen by
injecting a small amount of air. Once this was accomplished, we use
introducer and a dilator over a guidewire to enter the jejunal lumen.
The dilator and the guidewire were removed and the needle jejunostomy
was threaded for about 20 cm. The introducer then was removed. We
then placed 2-0 stitch with V-lock to Witzel the jejunostomy. We then
proceeded to put a pursestring suture with Endo-stitch and tacked the
jejunostomy to anterior wall with an Endo-Stitch. Once this was
accomplished, the jejunostomy was fixed to the skin with Nylon and
covered with a transparent dressing. The trocar that was inserted in
the midline, the incision was closed with a 0 Vicryl and then the
skin was approximated with subcuticular 3-0 Vicryl and covered with
sterile dressings. Once the abdominal part was completed, the patient
was placed on the lateral decubitus position and Dr. Williams
proceeded to do the thoracotomy. A 12 mm trocar then was placed at
the level of the mid-axillary line in the 8th intercostal space,
through which the pneumothorax was achieved after the
anesthesiologist collapsed the right lung. Under direct
thoracoscopic vision, a mini thoracotomy was done in between the 4th
and 5th ribs. Once inside the thoracic cavity through the mini
thoracotomy, we proceeded to do the mediastinal dissection. Two
additional trocars were placed to pass instruments to be able to
retract the lung and be able to do an adequate exposure. The azygos
vein was identified and stapled and transected with an Endo-GIA tan
load that measured 60 mm. The mediastinal dissection then was
continued using the Harmonic scalpel to the level of thoracic inlet.
The most challenging part of the dissection was in the mid esophagus
where the tumor was adherent to the pleura. However, with a
combination of sharp and blunt dissection, the mediastinal dissection
was completed. Once this was accomplished, the esophagus was
transected at the junction of the proximal 3rd with the distal 2/3.
Hard cork Metzenbaum scissors was used to transect the esophagus at
the anesthesiologist had retrieved the esophageal thermometer and the
nasogastric tube. At this point, the stomach was brought into the
thoracic cavity and we proceeded to create the gastric conduit. The
Endo-GIA stapler was passed through the trocar and the stomach was
transected at the level of the fundus. The stomach then was an
elongated and with the Endo-GIA, we proceeded to create the gastric
conduit requiring five applications of the 45 mm Endo-GIA purple
load. Once this was accomplished, the specimen was removed and sent
to pathology for frozen section for the proximal esophageal margin.
While the pathologist was looking at the margins, we proceeded to
place a pursestring suture using 3-0 Prolene in the open end of the
proximal esophagus. The patient was given 1 mg of intravenous
Glucagon for smooth muscle relaxation and then the esophagus was
dilated with a Foley catheter placed intraluminally and 10 mL
injected into the Foley bag. While the Foley was distending the
esophagus, Dr. W placed a pursestring suture with 2-0 Prolene.
Once the pursestring suture was in place, we used 28 EEA circular
stapler for the anastomosis. The anvil was placed in the proximal
esophagus. The pursestring suture was secured and tied around the
column of the anvil. Once this was in place, we introduced a 28 mm
EEA stapler through the trocar entry site in the lateral chest wall.
We performed a gastrotomy on the gastric wall through which the
stapler was passed. Once the stapler was in place, the spike of the
EEA was brought out through the posterior gastric wall, attached to
the anvil, closed and fired obtaining two intact tissue donuts. The
anesthesiologist then passed the NG tube distal to the
esophagogastric anastomosis. The gastrotomy was then closed after
approximating the edges with interrupted 3-0 silk with an Endo-GIA
purple cartridge. Once the gastrotomy was closed, we proceeded to
place a 10 mm Blake drain lateral to the gastric conduit that was
brought out through one of the trocar entry sites on the lateral
chest wall. The chest wall was closed with a double-stranded number 1
PDS to approximate the ribs and then the skin was approximated with
subcuticular 3-0 Vicryl. An On-Q continuous infusion system for
postoperative analgesia was left in place in the lower region of the
superior and inferior edges of the incision. Number 32 chest tube
was placed and brought out through the trocar insertion site and held
in place with Ethibond. At the end of the procedure, the patient was
placed supine. The bronchial dividing tube was removed and a single
lumen endotracheal tube was placed. The patient remained intubated,
transferred to the recovery room and eventually to the intensive care
unit.
Can someone please help me with this report I'm so
, I'm reading over and over and I don't know where to begin coding this report, but so far I'm looking at these code but I'm not completely sure 43117, 44300, and 32674
Thanks in advance for any suggestion or help you can provide me with....
1. Squamous cell carcinoma of the middle esophagus.
2. Esophageal obstruction with odynophagia.
POSTOPERATIVE DIAGNOSIS:
1. Squamous cell carcinoma of the middle esophagus.
2. Esophageal obstruction with odynophagia.
PROCEDURE PERFORMED:
1. Laparoscopically robotic minimally invasive thoracoabdominal near
total esophagectomy with intrathoracic gastroesophageal
anastomosis.
2. Laparoscopic placement of feeding jejunostomy.
3. Retroperitoneal lymph node dissection.
4. Mediastinal lymph node dissection.
SURGEON:
Dr. L (surgical oncology).
CO-SURGEON:
Dr. W (thoracic surgery)
FIRST ASSISTANT:
S, M.D.
SECOND ASSISTANT:
B., PA-C.
ANESTHESIA:
General endotracheal.
ATTENDING ANESTHESIOLOGIST:
Dr. K.
ESTIMATED BLOOD LOSS:
300 mL.
COMPLICATIONS:
None.
SPECIMENS REMOVED:
1. Distal 2/3 of the esophagus and proximal stomach with attached
mediastinal and retroperitoneal lymph nodes. The specimen also
contained the lymph nodes of the lesser curvature.
2. Anastomotic donuts from the esophagogastric anastomosis. By frozen
section, the initial margin of resection was positive for
infiltrating squamous cell carcinoma. However, the second and
final margin from the tissue donuts was negative for malignancy.
JUSTIFICATION FOR THE PROCEDURE:
Mr. V. is a 82-year-old male that was admitted to
Hospital through the emergency room yesterday after visiting
the office of Dr. W. The patient has mid esophageal cancer
that has produced complete obstruction and has been diagnosed by
biopsy as a squamous cell carcinoma. The patient has had restaging
studies with CT scan of the chest, abdomen, and pelvis and there is
no evidence by imaging of metastatic disease.
With these findings, the patient comes for minimally invasive near
total esophagectomy.
FINDINGS:
In the abdominal part of the procedure, there was no evidence of
disseminated disease in the abdomen. The liver appeared to be free of
metastases and the lymph nodes in the retroperitoneum as well as the
lesser curvature did not appear to contain metastatic disease. In the
mediastinum, the most significant finding was the tumor immediately
adjacent and adherent to the pericardium. The lymph nodes did not
appear to be grossly enlarged but were firm and fibrotic consistent
with either metastatic disease or desmoplastic reaction. Once the
procedure was completed, all gross evidence of disease had been
removed. There was no gross evidence of residual disease.
INFORMED CONSENT:
In the holding area before the patient was brought to the operating
room, the patient signed an informed written consent, after myself
and Dr. W. explained to him in detail the purpose of the
procedure, the risks associated with the surgery. The risks quoted to
the patient included anastomotic leak, injury to intra-abdominal or
thoracic structures, bleeding, infection, and complications related
to general endotracheal anesthesia such as deep vein thrombosis,
pulmonary emboli, and cardiac complications.
PATIENT IDENTIFICATION:
In the operating room, before the procedure was started, we took a
"time-out" to properly identify the patient by name, as well as
intended surgical procedure. Once the nurse anesthetist and the
circulating nurse agreed with the proper identification of the
patient, and intended surgical procedure, the operation was started
as described below.
PROCEDURE IN DETAIL:
The patient was placed supine on the operating table and after
satisfactory general endotracheal anesthesia, the anterior abdominal
wall was prepared sterile with Betadine solution and draped
sterilely. We then proceeded to make an incision above the umbilicus
through which a Veress needle was introduced and the pneumoperitoneum
was achieved. Once the pneumoperitoneum was achieved, we proceeded to
place 3 additional 8 mm trocars; the first one was located in the
left upper quadrant; the second one in the right upper quadrant; the
3rd one was in the left flank. We then introduced a 0.5 accessory
trocar in the left lower quadrant. During the case, a 5 mm trocar was
added to service an accessory port also in the right upper quadrant.
Once the trocars were in place, we docked the da Vinci robot. We
used a 30 degree camera looking down and the right arm, arm number
one, we used monopolar shears and arm number two on the left side, we
used a bipolar fenestrated grasper, and then arm number three on the
right side we used the ProGrasp grasper. We started by identifying
the last branch of the gastroepiploic artery and transecting the
greater omentum at this level. We then proceeded to transect the
short gastric vessels and cauterizing. We used the LigaSure
instrument for this purpose. Once we reached the fundus of the
stomach, we turned our attention to the lesser curvature. The
gastrohepatic ligament was incised using the shears next to the liver
and then continued cephalad until the gastroesophageal junction was
identified. The lymph node dissection from the lesser curvature was
carried out using the LigaSure instrument until we reached the
gastroesophageal junction where the lymph nodes were left attached to
the specimen. The left and right crus of the diaphragm were
identified and dissected with the monopolar shears. We then proceeded
to dissect the mediastinum all the way to the junction of the middle
3rd with the lower 3rd of the esophagus. After this dissection was
completed, we then proceeded to separate the posterior gastric wall
from the anterior pancreatic wall until we found the left gastric
artery. The left gastric artery was stapled and transected with a
purple Endo-GIA 60 mm. Once the left gastric artery was transected,
we proceeded to dissect the pylorus in order to mobilize it and
verify that it could reach the right crus of the diaphragm. Once this
was accomplished, we introduced an Intra-jet device through one of
the trocars and through the Intra-jet device, we injected the pylorus
for a chemical pyloroplasty. A total of 4 mL of the solution that
contained 100 units of Botox was injected into the pylorus. Once this
was accomplished, we proceeded to do the feeding jejunostomy. We
tacked the proximal jejunum 20 cm from the ligament of Treitz to the
anterior abdominal wall. We then used a needle jejunostomy to
puncture the jejunum and verified that we were inside the lumen by
injecting a small amount of air. Once this was accomplished, we use
introducer and a dilator over a guidewire to enter the jejunal lumen.
The dilator and the guidewire were removed and the needle jejunostomy
was threaded for about 20 cm. The introducer then was removed. We
then placed 2-0 stitch with V-lock to Witzel the jejunostomy. We then
proceeded to put a pursestring suture with Endo-stitch and tacked the
jejunostomy to anterior wall with an Endo-Stitch. Once this was
accomplished, the jejunostomy was fixed to the skin with Nylon and
covered with a transparent dressing. The trocar that was inserted in
the midline, the incision was closed with a 0 Vicryl and then the
skin was approximated with subcuticular 3-0 Vicryl and covered with
sterile dressings. Once the abdominal part was completed, the patient
was placed on the lateral decubitus position and Dr. Williams
proceeded to do the thoracotomy. A 12 mm trocar then was placed at
the level of the mid-axillary line in the 8th intercostal space,
through which the pneumothorax was achieved after the
anesthesiologist collapsed the right lung. Under direct
thoracoscopic vision, a mini thoracotomy was done in between the 4th
and 5th ribs. Once inside the thoracic cavity through the mini
thoracotomy, we proceeded to do the mediastinal dissection. Two
additional trocars were placed to pass instruments to be able to
retract the lung and be able to do an adequate exposure. The azygos
vein was identified and stapled and transected with an Endo-GIA tan
load that measured 60 mm. The mediastinal dissection then was
continued using the Harmonic scalpel to the level of thoracic inlet.
The most challenging part of the dissection was in the mid esophagus
where the tumor was adherent to the pleura. However, with a
combination of sharp and blunt dissection, the mediastinal dissection
was completed. Once this was accomplished, the esophagus was
transected at the junction of the proximal 3rd with the distal 2/3.
Hard cork Metzenbaum scissors was used to transect the esophagus at
the anesthesiologist had retrieved the esophageal thermometer and the
nasogastric tube. At this point, the stomach was brought into the
thoracic cavity and we proceeded to create the gastric conduit. The
Endo-GIA stapler was passed through the trocar and the stomach was
transected at the level of the fundus. The stomach then was an
elongated and with the Endo-GIA, we proceeded to create the gastric
conduit requiring five applications of the 45 mm Endo-GIA purple
load. Once this was accomplished, the specimen was removed and sent
to pathology for frozen section for the proximal esophageal margin.
While the pathologist was looking at the margins, we proceeded to
place a pursestring suture using 3-0 Prolene in the open end of the
proximal esophagus. The patient was given 1 mg of intravenous
Glucagon for smooth muscle relaxation and then the esophagus was
dilated with a Foley catheter placed intraluminally and 10 mL
injected into the Foley bag. While the Foley was distending the
esophagus, Dr. W placed a pursestring suture with 2-0 Prolene.
Once the pursestring suture was in place, we used 28 EEA circular
stapler for the anastomosis. The anvil was placed in the proximal
esophagus. The pursestring suture was secured and tied around the
column of the anvil. Once this was in place, we introduced a 28 mm
EEA stapler through the trocar entry site in the lateral chest wall.
We performed a gastrotomy on the gastric wall through which the
stapler was passed. Once the stapler was in place, the spike of the
EEA was brought out through the posterior gastric wall, attached to
the anvil, closed and fired obtaining two intact tissue donuts. The
anesthesiologist then passed the NG tube distal to the
esophagogastric anastomosis. The gastrotomy was then closed after
approximating the edges with interrupted 3-0 silk with an Endo-GIA
purple cartridge. Once the gastrotomy was closed, we proceeded to
place a 10 mm Blake drain lateral to the gastric conduit that was
brought out through one of the trocar entry sites on the lateral
chest wall. The chest wall was closed with a double-stranded number 1
PDS to approximate the ribs and then the skin was approximated with
subcuticular 3-0 Vicryl. An On-Q continuous infusion system for
postoperative analgesia was left in place in the lower region of the
superior and inferior edges of the incision. Number 32 chest tube
was placed and brought out through the trocar insertion site and held
in place with Ethibond. At the end of the procedure, the patient was
placed supine. The bronchial dividing tube was removed and a single
lumen endotracheal tube was placed. The patient remained intubated,
transferred to the recovery room and eventually to the intensive care
unit.
Can someone please help me with this report I'm so
, I'm reading over and over and I don't know where to begin coding this report, but so far I'm looking at these code but I'm not completely sure 43117, 44300, and 32674Thanks in advance for any suggestion or help you can provide me with....