My doc did a open lobectomy on a post chemo patient. She also had to do extensive chest wall resection due to the effects of the chemo in addition to a lobectomy. 32480 does seem sufficient to encompass all the work. Chest wall resection points to code 19260 which does seem appropriate. Any ideas?
PROCEDURE PERFORMED:
1. Flexible bronchoscopy.
2. Mediastinoscopy.
3. Left thoracotomy and left upper lobe lobectomy with en bloc chest wall resection.
. A posterolateral muscle-sparing thoracotomy incision was done. Initially the rib-spreading retractor was placed, but the lung was visualized to be adherent to the chest wall and not visible through the thoracotomy incision. A chest tube incision was made anteroinferiorly and a thoracoscope inserted through this. Via thoracoscopic visualization, we were able to take the lung down partially off the chest wall, but it soon became apparent that the subpleural plane was not adequate for removal of the lung from the chest wall, that there had been chest wall invasion and this required chest wall resection.
Using Bovie cautery, the planned chest wall resection was marked, and this encompassed ribs 2, 3 and 4. The intercostal bundles were sequentially tied and the anterior and posterior portion of the ribs cut with rib cutters. The intercostal muscle cephalad to the second rib was taken down and this allowed visualization through the chest wall opening. The lung was still significantly adherent posteriorly at the apex, but this appeared to be radiation change and not invasion. Slowly the lung was taken down using a combination of blunt and cautery dissection. Eventually it was freed from the apex and able to be rotated anteriorly, exposing the posterior hilum.
The pleura was opened on the posterior aspect of the hilum, and there was significant fibrosis in the plane between the tumor and the pulmonary artery. We proceeded with dissection within the fissure and took down upper lobe branches as we encountered them, dissecting them from the radiated tissue mostly with sharp section. Most branches were divided with silk ties and 2-0 stick tie. Once the anterior branches were divided, the superior pulmonary vein was encircled and divided with a vascular load of the stapler. The upper lobe bronchus was then freed, encircled, and divided with the purple load of the stapler as well. This left three large PA branches which were just beyond the tumor bed and quite short. The posterior aspect of the fissure was opened as the artery was dissected from the posterior aspect of the lung. The superior segment was pulled up somewhat into the radiation bed but did not appear to be involved by tumor. Once we were able to pass an instrument from the posterior aspect of the pulmonary artery to the posterior hilum, we divided the tip of the superior segment rather than right at the fissure with several loads of purple and black loads of the Universal stapler. Elevating this revealed the final three PA branches. The snare was taken down as it was clear that the most posterior branch needed to be transected and closed primarily. Once the artery was snared, the posterior branch was cut with Metzenbaum scissors and closed with 4-0 Prolene primarily. The additional branches were encircled, ligated with heavy silk ties, 2-0 stick ties, and divided sharply. Once this was complete, the lobe was passed off the table as specimen
Nicole, CPC
PROCEDURE PERFORMED:
1. Flexible bronchoscopy.
2. Mediastinoscopy.
3. Left thoracotomy and left upper lobe lobectomy with en bloc chest wall resection.
. A posterolateral muscle-sparing thoracotomy incision was done. Initially the rib-spreading retractor was placed, but the lung was visualized to be adherent to the chest wall and not visible through the thoracotomy incision. A chest tube incision was made anteroinferiorly and a thoracoscope inserted through this. Via thoracoscopic visualization, we were able to take the lung down partially off the chest wall, but it soon became apparent that the subpleural plane was not adequate for removal of the lung from the chest wall, that there had been chest wall invasion and this required chest wall resection.
Using Bovie cautery, the planned chest wall resection was marked, and this encompassed ribs 2, 3 and 4. The intercostal bundles were sequentially tied and the anterior and posterior portion of the ribs cut with rib cutters. The intercostal muscle cephalad to the second rib was taken down and this allowed visualization through the chest wall opening. The lung was still significantly adherent posteriorly at the apex, but this appeared to be radiation change and not invasion. Slowly the lung was taken down using a combination of blunt and cautery dissection. Eventually it was freed from the apex and able to be rotated anteriorly, exposing the posterior hilum.
The pleura was opened on the posterior aspect of the hilum, and there was significant fibrosis in the plane between the tumor and the pulmonary artery. We proceeded with dissection within the fissure and took down upper lobe branches as we encountered them, dissecting them from the radiated tissue mostly with sharp section. Most branches were divided with silk ties and 2-0 stick tie. Once the anterior branches were divided, the superior pulmonary vein was encircled and divided with a vascular load of the stapler. The upper lobe bronchus was then freed, encircled, and divided with the purple load of the stapler as well. This left three large PA branches which were just beyond the tumor bed and quite short. The posterior aspect of the fissure was opened as the artery was dissected from the posterior aspect of the lung. The superior segment was pulled up somewhat into the radiation bed but did not appear to be involved by tumor. Once we were able to pass an instrument from the posterior aspect of the pulmonary artery to the posterior hilum, we divided the tip of the superior segment rather than right at the fissure with several loads of purple and black loads of the Universal stapler. Elevating this revealed the final three PA branches. The snare was taken down as it was clear that the most posterior branch needed to be transected and closed primarily. Once the artery was snared, the posterior branch was cut with Metzenbaum scissors and closed with 4-0 Prolene primarily. The additional branches were encircled, ligated with heavy silk ties, 2-0 stick ties, and divided sharply. Once this was complete, the lobe was passed off the table as specimen
Nicole, CPC