valerieeanderson
Networker
I could really use some help with the CPT for this OP note. I'm fairly certain I will have to use the unlisted lap CPT 51999 but not sure I've got the best compare-to CPTs.
I'm considering: 51999 compare to 50820 and I'm stuck on the pelvic exoneration. Any insights would be helpful and very much appreciated.
Procedure: She was prepped and draped in sterile fashion after a successful induction with general anesthesia in the standard low lithotomy position. A time out was performed. A 20Fr foley catheter was placed per urethra and into the bladder without difficulty. A betadine soaked sponge stick was placed in the vagina. Access to the peritoneum was obtained with a veress needle through a supraumbilical stab wound. 0.5% marcaine was used for local anesthesia. Once successful pneumoperitoneum was created an 8mm port was placed under direct vision. The 2 right robotic ports, left robotic port and left upper quadrant assistant port were all placed under direct vision. The robot was docked and the dissection ensued robotically. The left colon was mobilized medially along the white line exposing the left common iliac vessels. The ureter was identified here and isolated over the iliac vessels with blunt dissection and cautery. The peritoneum was opened over the ureter down into the pelvis. The ureter was completely mobilized as far as possible posterior to the bladder. The same dissection was performed on the right, all the way to the posterior aspect of the bladder. Cautery was used to open the prevesical space lateral to the obliterated ligament on either side. Dissection was the carried lateral to the bladder on either side down to the distal ureter. The pedical was then skeletonized lateral to the ureter on both sides. The vessel sealer was used on the pedicles. This allowed further dissection of the ureters to the bladder. The ureters were then divided distally between 2 hemolock clips. Tension was placed on the bladder anteriorly. The peritoneal incision was made between the ureters transversely. I opened the vagina near the apex and dissected the anterior vaginal wall off the bladder; this plane developed nicely and there did not appear to be any reaction or malignancy in this plane. The incisions lateral to the bladder were now extended anteriorly as far as possible. The ligaments were fulgurated and transected as far anterior as possible. The peritoneal incision was joined transversely and the bladder dropped off the abdominal pelvic wall and pulled posteriorly. The left anterior bladder was adherent to the posterior rectus sheath on that side. The endopelvic fascia was incised along both sides of the bladder neck. The urethra was dissected away form the anterior vaginal wall and opened distally near the meatus. The foley was removed and the bladder neck closed with 3-0 v-lock. The bladder was now completely mobilized and placed into the upper abdomen. The vaginal cuff was closed with 2-0 vicryl. An 18 Fr council foley was placed in the urethra to eliminate gas leak.
The pelvic lymph node was inspected and there was no significant tissue noted. The obturator fossae and iliacs were all skeletonized up to medial to the ureters after completion of the cystectomy. I did not do a separate node dissection. There were no suspicious nodes grossly. There was nowsignificant bleeding noted at this time.
The ileal loop urinary diversion was now performed. The cecum was identified. Using a measuring tape, a 20cm segment of distal ileum was identified ending 20cm proximal to the ileocecal valve. The mesentery was opened at the distal extent the the ileum was transected with the 45mm endovascular stapler. The same technique was used at the proximal extent. The mesentery was then taken down proximally and distally with the vessel sealer. Bowel continuity was established in a side to side fashion. A small defect was made on the antimesenteric border of each ileal stump. The stapler was placed and then fired along the antimesenteric border. The remaining defect was then closed by hand with running 2-0 vicryl mucosal closure and running 3-0 silk imbricating seromuscular closure. The left ureter was brought to the right pelvis through a small defect in the sigmoid mesocolon taking care not to twist or kink the ureter. The clips were then removed from the ureters and the ureters were widely spatulated. This distal staple line was removed from the isolated ileal segment. The segment was irrigatd until clear. An opening was made near the proximal end of the ileal loop and the left ureter was joined here. Once the posterior anastamosis was complete, single J stent was then placed in the ureter. The stent was then brought out the distal end of the the ileal loop. The anterior anasatmosis was then completed. The same technique was used for the right ureter at the anterior base of the ileal loop. The ileal loop was irrigated. The ureters are noted to distend and no extravasation was noted. No bleeding was noted.
Next a pfannenstiel incision was made in her scar. Cautery was used to expose the midline fascia. The fascia was opened transversely and the rectus were separated. The abdomen was entered and deflated. The specimens were removed and sent for routine pathology. The ports were all removed. Her proposed stoma site was too high to use. I selected a site below the umbilicus to the right, in the rectus. A half dollar size piece of skin was removed along with all subcutaneous tissue. The anterior rectus sheath was then opened in a cruciate fashion away from the port site defect in the fascia. The body of the rectus was split And the posterior sheath was opened. The defect accomodates 2 fingers. 2-0 vicryl stitches were placed in each of 4 fascial corners. Using a babcock clamp the ileal loop was brought through the proposed stoma site. The fascial sutures were then placed through the seromuscular layer of the ileum. The stoma was then matured with 2-0 vicryl in 4 corners followed by 2-0 vicryl mucocutaneous closure. A 10Fr round JP drain was placed through the left robotic port site in proximity to the ileal loop. The fascia was then closed with 0PDS. Fascia at the assist port site was closed with 2-0 vicryl. Skin was then closed with 4-0 monocryl subcuticular suture at all sites followed by dermabond. A ostomy appliance was then placed. Urine is noted to be draining from both stents.
Tolerated the procedure well and was taken to the recovery room in stable condition.
Specimens:
1 : 1) left distal ureter
2 : 2) right distal ureter
3 : 3) bladder, uterus, cervix, bilateral tubes and ovaries
I'm considering: 51999 compare to 50820 and I'm stuck on the pelvic exoneration. Any insights would be helpful and very much appreciated.
Procedure: She was prepped and draped in sterile fashion after a successful induction with general anesthesia in the standard low lithotomy position. A time out was performed. A 20Fr foley catheter was placed per urethra and into the bladder without difficulty. A betadine soaked sponge stick was placed in the vagina. Access to the peritoneum was obtained with a veress needle through a supraumbilical stab wound. 0.5% marcaine was used for local anesthesia. Once successful pneumoperitoneum was created an 8mm port was placed under direct vision. The 2 right robotic ports, left robotic port and left upper quadrant assistant port were all placed under direct vision. The robot was docked and the dissection ensued robotically. The left colon was mobilized medially along the white line exposing the left common iliac vessels. The ureter was identified here and isolated over the iliac vessels with blunt dissection and cautery. The peritoneum was opened over the ureter down into the pelvis. The ureter was completely mobilized as far as possible posterior to the bladder. The same dissection was performed on the right, all the way to the posterior aspect of the bladder. Cautery was used to open the prevesical space lateral to the obliterated ligament on either side. Dissection was the carried lateral to the bladder on either side down to the distal ureter. The pedical was then skeletonized lateral to the ureter on both sides. The vessel sealer was used on the pedicles. This allowed further dissection of the ureters to the bladder. The ureters were then divided distally between 2 hemolock clips. Tension was placed on the bladder anteriorly. The peritoneal incision was made between the ureters transversely. I opened the vagina near the apex and dissected the anterior vaginal wall off the bladder; this plane developed nicely and there did not appear to be any reaction or malignancy in this plane. The incisions lateral to the bladder were now extended anteriorly as far as possible. The ligaments were fulgurated and transected as far anterior as possible. The peritoneal incision was joined transversely and the bladder dropped off the abdominal pelvic wall and pulled posteriorly. The left anterior bladder was adherent to the posterior rectus sheath on that side. The endopelvic fascia was incised along both sides of the bladder neck. The urethra was dissected away form the anterior vaginal wall and opened distally near the meatus. The foley was removed and the bladder neck closed with 3-0 v-lock. The bladder was now completely mobilized and placed into the upper abdomen. The vaginal cuff was closed with 2-0 vicryl. An 18 Fr council foley was placed in the urethra to eliminate gas leak.
The pelvic lymph node was inspected and there was no significant tissue noted. The obturator fossae and iliacs were all skeletonized up to medial to the ureters after completion of the cystectomy. I did not do a separate node dissection. There were no suspicious nodes grossly. There was nowsignificant bleeding noted at this time.
The ileal loop urinary diversion was now performed. The cecum was identified. Using a measuring tape, a 20cm segment of distal ileum was identified ending 20cm proximal to the ileocecal valve. The mesentery was opened at the distal extent the the ileum was transected with the 45mm endovascular stapler. The same technique was used at the proximal extent. The mesentery was then taken down proximally and distally with the vessel sealer. Bowel continuity was established in a side to side fashion. A small defect was made on the antimesenteric border of each ileal stump. The stapler was placed and then fired along the antimesenteric border. The remaining defect was then closed by hand with running 2-0 vicryl mucosal closure and running 3-0 silk imbricating seromuscular closure. The left ureter was brought to the right pelvis through a small defect in the sigmoid mesocolon taking care not to twist or kink the ureter. The clips were then removed from the ureters and the ureters were widely spatulated. This distal staple line was removed from the isolated ileal segment. The segment was irrigatd until clear. An opening was made near the proximal end of the ileal loop and the left ureter was joined here. Once the posterior anastamosis was complete, single J stent was then placed in the ureter. The stent was then brought out the distal end of the the ileal loop. The anterior anasatmosis was then completed. The same technique was used for the right ureter at the anterior base of the ileal loop. The ileal loop was irrigated. The ureters are noted to distend and no extravasation was noted. No bleeding was noted.
Next a pfannenstiel incision was made in her scar. Cautery was used to expose the midline fascia. The fascia was opened transversely and the rectus were separated. The abdomen was entered and deflated. The specimens were removed and sent for routine pathology. The ports were all removed. Her proposed stoma site was too high to use. I selected a site below the umbilicus to the right, in the rectus. A half dollar size piece of skin was removed along with all subcutaneous tissue. The anterior rectus sheath was then opened in a cruciate fashion away from the port site defect in the fascia. The body of the rectus was split And the posterior sheath was opened. The defect accomodates 2 fingers. 2-0 vicryl stitches were placed in each of 4 fascial corners. Using a babcock clamp the ileal loop was brought through the proposed stoma site. The fascial sutures were then placed through the seromuscular layer of the ileum. The stoma was then matured with 2-0 vicryl in 4 corners followed by 2-0 vicryl mucocutaneous closure. A 10Fr round JP drain was placed through the left robotic port site in proximity to the ileal loop. The fascia was then closed with 0PDS. Fascia at the assist port site was closed with 2-0 vicryl. Skin was then closed with 4-0 monocryl subcuticular suture at all sites followed by dermabond. A ostomy appliance was then placed. Urine is noted to be draining from both stents.
Tolerated the procedure well and was taken to the recovery room in stable condition.
Specimens:
1 : 1) left distal ureter
2 : 2) right distal ureter
3 : 3) bladder, uterus, cervix, bilateral tubes and ovaries