amanda19791
Networker
Need advice. My provider performed a pectus repair with cryoablation therapy. The codes used are 21743 & C2618... I have not seen this before. I wanted to know if the cryoablation therapy is part of the surgery? See Op note.
Procedure:
The patient was identified and placed in the supine position on the operating table. Adequate anesthesia was induced with a double-lumen endotracheal tube.. Foley catheter was placed using sterile technique. Timeout was performed and all present were in agreement. Antibiotics were administered and the chest was prepped and draped in sterile fashion with an ioband. The highpoints on either side of the depressed sternum were marked and the chest measured between the mid-axillary lines. This distance was measured to be 14.5 inches and a 13.5 inch Biomet bar was then selected. Incisions were made on either side of the chest transversely from the anterior to the mid axillary line and the pectoralis muscle was reflected to expose the chest and pockets were created for the bar. For optimal postoperative pain control I decided that cryoablation was indicated in this child. A 5 mm step trocar was passed into the fifth intercostal space through the incision on the right side of the chest as the anesthetist isolated the lung performing one lung ventilation on the left side. Under direct vision a second 10 mm step trocar was directed through a separate incision in the right chest at the nipple line and seventh intercostal space. Through this the cryoablation probe was directed into the chest and used to ablate the intercostal nerves starting at the third intercostal space down to the eighth intercostal space. The probe was placed between 5 to 7 cm lateral to the spine. This was performed under direct vision taking care to avoid contact of the lung with the probe. The probe was held at each space for 2 minutes according to protocol. We then waited the requisite 2 minutes after the probe was removed to allow the ice balls to thaw in the chest wall and then the lung was reinflated isolating the left lung so that single lung ventilation on the right side could be performed. In similar fashion a 5 mm step trocar was introduced into the fifth intercostal space in the left chest through the existing incision and under direct vision the second 10 mm step trocar was passed at the anterior axillary line in the seventh intercostal space. The cryoablation probe was reinserted to the 10 mm step trocar into the left chest and ablation was again performed starting at the third through the eighth intercostal space about 5 to 7 cm lateral to the spine. This was under direct vision and care was taken to avoid contacting the pericardium or lung with the probe. The pectus bar was then custom bent on the back table to conform to the chest wall with care being taken to allow for the asymmetry of the defect. The probe was removed and we waited the requisite 2 minutes to allow the ice ball to thaw before reinflating the lung I am going to double lung ventilation. The pectus bar was then custom bent on the back table to conform to the chest wall with care being taken to allow for the asymmetry of the defect. A 5 mm Step port was placed between the ribs in the right chest below the incision and the chest insufflated to 5 mm Hg pressure. The 5 mm thorascope was directed into the right chest for visualization. The introducer was then placed through the right chest incision and between the ribs at the high point of the defect and into the chest lateral to the mammary vessels. Under direct vision, the introducer was advanced across the mediastinum behind the sternum with care being taken to dissect the avascular tissue in front of the heart and so avoid injury to the pericardium. The introducer was then directed back out of the left chest at the high point of the defect between the ribs. The introducer was then lifted up and pressure was used to mold the anterior chest wall. Visualizing the amount of correction, I decided to place a second bar below the first for added stability. Because of the tapering of his chest I decided to use a 13 inch bar which was bent similar to the first. An umbilical tape was then placed on the introducer and the introducer withdrawn leaving the tape in place. The tape was secured to the pectus bar which was then directed into the chest through the dissected passage under direct vision. The bar was flipped and noted to conform well to the chest wall. Not needing any additional shaping, it was tucked into the pockets on both sides. Under direct thorascopic vision, an introducer was placed into the space below the first bar, across the mediastinum in the avascular plane and out of the premarked rib space on the left side of the chest. An umbilical tape was then placed on the end of the bar and the introducer was brought back across mediastinum under direct vision leaving the umbilical tape in place. The second bar was inserted under direct vision in similar fashion to the first. The stabilizers were inserted onto the ends of the bars on the left side and secured with #5 fiberwire. The right side of each bar was secured to the underlying ribs with three interrupted 0 PDS sutures with the assistance of an endoclose device under direct thorascopic vision. Rib blocks were performed under direct vision with bupivacaine. The fascia was closed over the ends of the bar in each incision with 2-0 Vicryl suture and the dermis closed with running 4-0 Vicryl. The skin was closed with running 4-0 Monocryl and Surgiseal was applied as a sterile dressing. The Step trocar was removed and after placing a Vicryl purse-string suture in the defect, an 18 French red Robinell catheter directed into the right chest and the distal end placed under water. The anesthetist gave several deep breaths to evacuate the air out of the chest. When no bubbles were noted, the catheter was removed and the purse-string secured. The skin was closed with a 4-0 Monocryl suture and Surgiseal applied. A chest xray was obtained and approximate 20% apical pneumothoraces were noted on both sides. Decided to place a chest tube to allow the lung to completely reexpand with the idea that this will be removed within 24 to 48 hours. Using the thorascopic incision on the right side a 24 French chest tube was directed over a rib and into the right chest and connected to 20 cm of water suction through a Pleur-evac. The child was awakened from anesthesia. The procedure was well tolerated, and there were no complications.
Procedure:
The patient was identified and placed in the supine position on the operating table. Adequate anesthesia was induced with a double-lumen endotracheal tube.. Foley catheter was placed using sterile technique. Timeout was performed and all present were in agreement. Antibiotics were administered and the chest was prepped and draped in sterile fashion with an ioband. The highpoints on either side of the depressed sternum were marked and the chest measured between the mid-axillary lines. This distance was measured to be 14.5 inches and a 13.5 inch Biomet bar was then selected. Incisions were made on either side of the chest transversely from the anterior to the mid axillary line and the pectoralis muscle was reflected to expose the chest and pockets were created for the bar. For optimal postoperative pain control I decided that cryoablation was indicated in this child. A 5 mm step trocar was passed into the fifth intercostal space through the incision on the right side of the chest as the anesthetist isolated the lung performing one lung ventilation on the left side. Under direct vision a second 10 mm step trocar was directed through a separate incision in the right chest at the nipple line and seventh intercostal space. Through this the cryoablation probe was directed into the chest and used to ablate the intercostal nerves starting at the third intercostal space down to the eighth intercostal space. The probe was placed between 5 to 7 cm lateral to the spine. This was performed under direct vision taking care to avoid contact of the lung with the probe. The probe was held at each space for 2 minutes according to protocol. We then waited the requisite 2 minutes after the probe was removed to allow the ice balls to thaw in the chest wall and then the lung was reinflated isolating the left lung so that single lung ventilation on the right side could be performed. In similar fashion a 5 mm step trocar was introduced into the fifth intercostal space in the left chest through the existing incision and under direct vision the second 10 mm step trocar was passed at the anterior axillary line in the seventh intercostal space. The cryoablation probe was reinserted to the 10 mm step trocar into the left chest and ablation was again performed starting at the third through the eighth intercostal space about 5 to 7 cm lateral to the spine. This was under direct vision and care was taken to avoid contacting the pericardium or lung with the probe. The pectus bar was then custom bent on the back table to conform to the chest wall with care being taken to allow for the asymmetry of the defect. The probe was removed and we waited the requisite 2 minutes to allow the ice ball to thaw before reinflating the lung I am going to double lung ventilation. The pectus bar was then custom bent on the back table to conform to the chest wall with care being taken to allow for the asymmetry of the defect. A 5 mm Step port was placed between the ribs in the right chest below the incision and the chest insufflated to 5 mm Hg pressure. The 5 mm thorascope was directed into the right chest for visualization. The introducer was then placed through the right chest incision and between the ribs at the high point of the defect and into the chest lateral to the mammary vessels. Under direct vision, the introducer was advanced across the mediastinum behind the sternum with care being taken to dissect the avascular tissue in front of the heart and so avoid injury to the pericardium. The introducer was then directed back out of the left chest at the high point of the defect between the ribs. The introducer was then lifted up and pressure was used to mold the anterior chest wall. Visualizing the amount of correction, I decided to place a second bar below the first for added stability. Because of the tapering of his chest I decided to use a 13 inch bar which was bent similar to the first. An umbilical tape was then placed on the introducer and the introducer withdrawn leaving the tape in place. The tape was secured to the pectus bar which was then directed into the chest through the dissected passage under direct vision. The bar was flipped and noted to conform well to the chest wall. Not needing any additional shaping, it was tucked into the pockets on both sides. Under direct thorascopic vision, an introducer was placed into the space below the first bar, across the mediastinum in the avascular plane and out of the premarked rib space on the left side of the chest. An umbilical tape was then placed on the end of the bar and the introducer was brought back across mediastinum under direct vision leaving the umbilical tape in place. The second bar was inserted under direct vision in similar fashion to the first. The stabilizers were inserted onto the ends of the bars on the left side and secured with #5 fiberwire. The right side of each bar was secured to the underlying ribs with three interrupted 0 PDS sutures with the assistance of an endoclose device under direct thorascopic vision. Rib blocks were performed under direct vision with bupivacaine. The fascia was closed over the ends of the bar in each incision with 2-0 Vicryl suture and the dermis closed with running 4-0 Vicryl. The skin was closed with running 4-0 Monocryl and Surgiseal was applied as a sterile dressing. The Step trocar was removed and after placing a Vicryl purse-string suture in the defect, an 18 French red Robinell catheter directed into the right chest and the distal end placed under water. The anesthetist gave several deep breaths to evacuate the air out of the chest. When no bubbles were noted, the catheter was removed and the purse-string secured. The skin was closed with a 4-0 Monocryl suture and Surgiseal applied. A chest xray was obtained and approximate 20% apical pneumothoraces were noted on both sides. Decided to place a chest tube to allow the lung to completely reexpand with the idea that this will be removed within 24 to 48 hours. Using the thorascopic incision on the right side a 24 French chest tube was directed over a rib and into the right chest and connected to 20 cm of water suction through a Pleur-evac. The child was awakened from anesthesia. The procedure was well tolerated, and there were no complications.