ealvarez113@hotmail.com
Networker
Dr. performed a Robotic assist laparoscopy pelvic tumor debulking. Im coming up with a 58662 or a 58679 unlisted code. Can someone please help me?
Operative note
Pre-Op Diagnosis Code: Pre-op Diagnosis
* Malignant neoplasm of ovary, unspecified laterality (CMS/HCC) C56.9
Post-Op Diagnosis Code: Post-op Diagnosis
* Malignant neoplasm of ovary, unspecified laterality (CMS/HCC) C56.9
PROCEDURE:
1. Robotic-assisted laparoscopic pelvic tumor debulking
2. Extensive lysis of adhesions.
3. Left ureterolysis.
Anesthesia: General endotracheal anesthesia
Findings: The patient had a large sigmoid colon mass of at least 5 cm size. Additionally, she had a right pelvic lymphocyst with clear fluid. This was excised. On the left pelvic sidewall, she had an approximately 3 x 4 cm pelvic nodule that was densely adherent to the pelvic sidewall as well as the left ureter, requiring left ureteral lysis, and ultimately also left ureteral stents performed by urology. There was additionally a left mesorectal nodule that was excised by Dr. en bloc with a portion of the rectum. Lastly, there was a mesenteric nodule near the sigmoid colon mass, that was also excised en bloc with the sigmoidectomy. There was a smaller tumor nodule on the sigmoid colon mesentery that was resected at the very beginning. The upper abdomen appeared within normal limits. There was no ascites. It did not appear to be other evidence of disease. She had extensive adhesive disease in the pelvis, requiring greater than 1 hour of adhesiolysis, lysin small bowel and the colon from each other in the pelvic sidewall peritoneum. Was extensive retroperitoneal fibrosis.
Indications: The patient was admitted to the hospital with a brief history of recurrent ovarian cancer, with persistent sigmoid colon mass despite recent chemotherapy. A CT scan of the abdomen pelvis revealed findings of additional pelvic tumor nodules, versus lymphocyst. The patient now presents for surgical management in the form of a sigmoid colectomy, pelvic tumor debulking, I the robotically assisted or open approach, after discussing therapeutic alternatives.
Procedure Details:
The patient was taken to the operating room, she was identified both
verbally and via wrist ID band. She was placed in the dorsal supine
lithotomy position with the legs in the Yellofin stirrups. General
endotracheal anesthesia was induced without any complication. An OG tube
was placed initially, and then removed at the end of the case.
A perioperative timeout was performed. Initially the patient was prepared
and draped in the usual sterile fashion. A transurethral Foley catheter
was introduced in the bladder. We turned our attention to the abdomen where in the left upper quadrant in Palmer's point just below the costal margin a small skin incision was made and the Veress needle was introduced. Saline drop test was negative.
Initial pneumoperitoneum was low and we achieved final pneumoperitoneum
at 15 mmHg. At this time, a small 8 mm skin incision was made several
centimeters above the umbilicus, and a 5 mm 0 degree Optiview scope and trocar were introduced here. There was no evidence of any intraabdominal injuries. The Veress needle was removed. Two 8 mm Xi ports were now placed on the left abdomen under direct visualization and a right upper quadrant 8 mm by port was placed as well followed by an 10mm AirSeal assistant port in the right lower quadrant.
The patient was placed in steep Trendelenburg. The above intraoperative findings were noted. The Xi robot was now docked. The console time was now started. Initially, we spent approximately an hour and a half taking down adhesions between the small bowel loops in the colon, as well as from the pelvis. Essentially the pelvis was recovered completely by the small bowel and the descending colon. The descending colon/sigmoid colon was mobilized from the lateral abdominal sidewall. The left retroperitoneal space was entered by incising along the left pelvic
sidewall peritoneum. The ureter was identified. At this time, the left pelvic sidewall mass that was apparently medial to the left superior vesicle artery, was skeletonized and resected. During this process, the ureter was encountered, and was noted to be very close but appeared to be uninjured this was later confirmed with firefly imaging by urology there was good vermiculation of this left ureter. It was further isolated, by releasing it from the surrounding tumor and the surrounding pelvic sidewall peritoneum. At this time, a tumor nodule was also noted superior to that, and was later identified to be in the mesorectum, and this was taken en bloc with the portion of the rectum with.
We turned our attention to the right hand side where in a similar fashion, the right retroperitoneal space was entered by incising along the right pelvic sidewall peritoneum. The ureter was identified on the right side transperitoneally. The right pelvic sidewall cyst was also skeletonized and noted to be a lymphocyst, with clear fluid. This was completely resected and sent to pathology.
Before the rectosigmoid colectomy, please see Dr. dictation for further details. The robot was undocked, all instruments removed. A small mini laparotomy was made by surgical oncology for a colorectal anastomosis. Following this, bubble test was negative.
We now irrigated and placed FloSeal and Surgicel in the left pelvis. There was good hemostasis throughout. We now removed all instruments, and closed the fascia with a running layer of 0 PDS, followed by subcuticular closure with 4-0 Monocryl. A round 19 Blake drain had been placed in the left pelvis. The assistant 10 mm port site was closed with UR6 needle at the fascia level. The skin incisions were closed with 4-0 Monocryl in a subcuticular fashion followed by Dermabond. At this time, urology came in and performed a left ureteral stent placement, given conservative management of a possible femoral injury during dissection of the left pelvic sidewall mass. Firefly imaging had been reassuring, revealing good flow of this left ureter. Please see details by the urology team for this portion of the surgery. The patient tolerated the procedure well. She went in stable condition to the PACU. All sponges and needle counts were correct x 2.
Operative note
Pre-Op Diagnosis Code: Pre-op Diagnosis
* Malignant neoplasm of ovary, unspecified laterality (CMS/HCC) C56.9
Post-Op Diagnosis Code: Post-op Diagnosis
* Malignant neoplasm of ovary, unspecified laterality (CMS/HCC) C56.9
PROCEDURE:
1. Robotic-assisted laparoscopic pelvic tumor debulking
2. Extensive lysis of adhesions.
3. Left ureterolysis.
Anesthesia: General endotracheal anesthesia
Findings: The patient had a large sigmoid colon mass of at least 5 cm size. Additionally, she had a right pelvic lymphocyst with clear fluid. This was excised. On the left pelvic sidewall, she had an approximately 3 x 4 cm pelvic nodule that was densely adherent to the pelvic sidewall as well as the left ureter, requiring left ureteral lysis, and ultimately also left ureteral stents performed by urology. There was additionally a left mesorectal nodule that was excised by Dr. en bloc with a portion of the rectum. Lastly, there was a mesenteric nodule near the sigmoid colon mass, that was also excised en bloc with the sigmoidectomy. There was a smaller tumor nodule on the sigmoid colon mesentery that was resected at the very beginning. The upper abdomen appeared within normal limits. There was no ascites. It did not appear to be other evidence of disease. She had extensive adhesive disease in the pelvis, requiring greater than 1 hour of adhesiolysis, lysin small bowel and the colon from each other in the pelvic sidewall peritoneum. Was extensive retroperitoneal fibrosis.
Indications: The patient was admitted to the hospital with a brief history of recurrent ovarian cancer, with persistent sigmoid colon mass despite recent chemotherapy. A CT scan of the abdomen pelvis revealed findings of additional pelvic tumor nodules, versus lymphocyst. The patient now presents for surgical management in the form of a sigmoid colectomy, pelvic tumor debulking, I the robotically assisted or open approach, after discussing therapeutic alternatives.
Procedure Details:
The patient was taken to the operating room, she was identified both
verbally and via wrist ID band. She was placed in the dorsal supine
lithotomy position with the legs in the Yellofin stirrups. General
endotracheal anesthesia was induced without any complication. An OG tube
was placed initially, and then removed at the end of the case.
A perioperative timeout was performed. Initially the patient was prepared
and draped in the usual sterile fashion. A transurethral Foley catheter
was introduced in the bladder. We turned our attention to the abdomen where in the left upper quadrant in Palmer's point just below the costal margin a small skin incision was made and the Veress needle was introduced. Saline drop test was negative.
Initial pneumoperitoneum was low and we achieved final pneumoperitoneum
at 15 mmHg. At this time, a small 8 mm skin incision was made several
centimeters above the umbilicus, and a 5 mm 0 degree Optiview scope and trocar were introduced here. There was no evidence of any intraabdominal injuries. The Veress needle was removed. Two 8 mm Xi ports were now placed on the left abdomen under direct visualization and a right upper quadrant 8 mm by port was placed as well followed by an 10mm AirSeal assistant port in the right lower quadrant.
The patient was placed in steep Trendelenburg. The above intraoperative findings were noted. The Xi robot was now docked. The console time was now started. Initially, we spent approximately an hour and a half taking down adhesions between the small bowel loops in the colon, as well as from the pelvis. Essentially the pelvis was recovered completely by the small bowel and the descending colon. The descending colon/sigmoid colon was mobilized from the lateral abdominal sidewall. The left retroperitoneal space was entered by incising along the left pelvic
sidewall peritoneum. The ureter was identified. At this time, the left pelvic sidewall mass that was apparently medial to the left superior vesicle artery, was skeletonized and resected. During this process, the ureter was encountered, and was noted to be very close but appeared to be uninjured this was later confirmed with firefly imaging by urology there was good vermiculation of this left ureter. It was further isolated, by releasing it from the surrounding tumor and the surrounding pelvic sidewall peritoneum. At this time, a tumor nodule was also noted superior to that, and was later identified to be in the mesorectum, and this was taken en bloc with the portion of the rectum with.
We turned our attention to the right hand side where in a similar fashion, the right retroperitoneal space was entered by incising along the right pelvic sidewall peritoneum. The ureter was identified on the right side transperitoneally. The right pelvic sidewall cyst was also skeletonized and noted to be a lymphocyst, with clear fluid. This was completely resected and sent to pathology.
Before the rectosigmoid colectomy, please see Dr. dictation for further details. The robot was undocked, all instruments removed. A small mini laparotomy was made by surgical oncology for a colorectal anastomosis. Following this, bubble test was negative.
We now irrigated and placed FloSeal and Surgicel in the left pelvis. There was good hemostasis throughout. We now removed all instruments, and closed the fascia with a running layer of 0 PDS, followed by subcuticular closure with 4-0 Monocryl. A round 19 Blake drain had been placed in the left pelvis. The assistant 10 mm port site was closed with UR6 needle at the fascia level. The skin incisions were closed with 4-0 Monocryl in a subcuticular fashion followed by Dermabond. At this time, urology came in and performed a left ureteral stent placement, given conservative management of a possible femoral injury during dissection of the left pelvic sidewall mass. Firefly imaging had been reassuring, revealing good flow of this left ureter. Please see details by the urology team for this portion of the surgery. The patient tolerated the procedure well. She went in stable condition to the PACU. All sponges and needle counts were correct x 2.